Disability and functional assessment in former polio patients with and without postpolio syndrome

Minimization of metabolic cost of transport predicts changes in gait mechanics over a range of ankle-foot orthosis stiffnesses in individuals with bilateral plantar flexor weakness

Neuromuscular disorders often lead to ankle plantar flexor muscle weakness, which impairs ankle push-off power and forward propulsion during gait. To improve walking speed and reduce metabolic cost of transport (mCoT), patients with plantar flexor weakness are provided dorsal-leaf spring ankle-foot orthoses (AFOs). It is widely believed that mCoT during gait depends on the AFO stiffness and an optimal AFO stiffness that minimizes mCoT exists. The biomechanics behind why and how an optimal stiffness exists and benefits individuals with plantar flexor weakness are not well understood. We hypothesized that the AFO would reduce the required support moment and, hence, metabolic cost contributions of the ankle plantar flexor and knee extensor muscles during stance, and reduce hip flexor metabolic cost to initiate swing. To test these hypotheses, we generated neuromusculoskeletal simulations to represent gait of an individual with bilateral plantar flexor weakness wearing an AFO with varying stiffness. Predictions were based on the objective of minimizing mCoT, loading rates at impact and head accelerations at each stiffness level, and the motor patterns were determined via dynamic optimization. The predictive gait simulation results were compared to experimental data from subjects with bilateral plantar flexor weakness walking with varying AFO stiffness. Our simulations demonstrated that reductions in mCoT with increasing stiffness were attributed to reductions in quadriceps metabolic cost during midstance. Increases in mCoT above optimum stiffness were attributed to the increasing metabolic cost of both hip flexor and hamstrings muscles. The insights gained from our predictive gait simulations could inform clinicians on the prescription of personalized AFOs. With further model individualization, simulations based on mCoT minimization may sufficiently predict adaptations to an AFO in individuals with plantar flexor weakness.

Two-year course of walking adaptability in persons living with late effects of polio

OBJECTIVE

To evaluate the 2-year course of walking adaptability in persons with late effects of polio.

DESIGN

Prospective cohort study.

PATIENTS

A total of 48 persons with late effects of polio (69% female, mean age 63.1 years) with a fall history and/or fear of falling.

METHODS

Walking adaptability (i.e. variable target-stepping and reactive obstacle-avoidance) was assessed on an interactive treadmill at baseline, 1 year and 2 years. Further, leg-muscle strength and balance were assessed at baseline. The course of walking adaptability was analysed with linear mixed models. Based on median values, subgroups were defined for low vs high baseline walking-adaptability and for clinical characteristics. Tme by subgroup interactions were analysed.

RESULTS

Variable target-stepping and reactive obstacle-avoidance did not change (p > 0.285). Reactive obstacle-avoidance improved for persons with a high balance score at baseline (p = 0.037), but not for those with lower scores (p = 0.531). No other time by subgroup interactions were found (p > 0.126).

CONCLUSION

Walking adaptability did not change in persons with late effects of polio over 2 years, and walking adaptability course did not differ between subgroups stratified for walking adaptability determinants, except for balance. Since falls are a major problem among persons with late effects of polio, future studies should investigate whether walking adaptability declines over a longer time and which persons are most at risk.

The interaction between muscle pathophysiology, body mass, walking speed and ankle foot orthosis stiffness on walking energy cost: a predictive simulation study

BACKGROUND

The stiffness of a dorsal leaf AFO that minimizes walking energy cost in people with plantarflexor weakness varies between individuals. Using predictive simulations, we studied the effects of plantarflexor weakness, passive plantarflexor stiffness, body mass, and walking speed on the optimal AFO stiffness for energy cost reduction.

METHODS

We employed a planar, nine degrees-of-freedom musculoskeletal model, in which for validation maximal strength of the plantar flexors was reduced by 80%. Walking simulations, driven by minimizing a comprehensive cost function of which energy cost was the main contributor, were generated using a reflex-based controller. Simulations of walking without and with an AFO with stiffnesses between 0.9 and 8.7 Nm/degree were generated. After validation against experimental data of 11 people with plantarflexor weakness using the Root-mean-square error (RMSE), we systematically changed plantarflexor weakness (range 40-90% weakness), passive plantarflexor stiffness (range: 20-200% of normal), body mass (+ 30%) and walking speed (range: 0.8-1.2 m/s) in our baseline model to evaluate their effect on the optimal AFO stiffness for energy cost minimization.

RESULTS

Our simulations had a RMSE < 2 for all lower limb joint kinetics and kinematics except the knee and hip power for walking without AFO. When systematically varying model parameters, more severe plantarflexor weakness, lower passive plantarflexor stiffness, higher body mass and walking speed increased the optimal AFO stiffness for energy cost minimization, with the largest effects for severity of plantarflexor weakness.

CONCLUSIONS

Our forward simulations demonstrate that in individuals with bilateral plantarflexor the necessary AFO stiffness for walking energy cost minimization is largely affected by severity of plantarflexor weakness, while variation in walking speed, passive muscle stiffness and body mass influence the optimal stiffness to a lesser extent. That gait deviations without AFO are overestimated may have exaggerated the required support of the AFO to minimize walking energy cost. Future research should focus on improving predictive simulations in order to implement personalized predictions in usual care. Trial Registration Nederlands Trial Register 5170. Registration date: May 7th 2015.  http://www.trialregister.nl/trialreg/admin/rctview.asp?TC=5170.

Functional exercise capacity in maximal and submaximal activities of individuals with polio sequelae

PURPOSE

Poliomyelitis is an infectious disease that can cause total paralysis. Furthermore, poliomyelitis survivors may develop new signs and symptoms, including muscular weakness and fatigue, years after the acute phase of the disease, i.e., post-polio syndrome (PPS). Thus, the objective was to compare the functional exercise capacity during maximal and submaximal exercises among individuals with polio sequelae (without PPS diagnosis), PPS, and a control group.

METHODS

Thirty individuals participated in three groups: a control group (CG, n = 10); a group of individuals with polio sequelae but without PPS diagnosis (PG, n = 10); and a PPS group (PPSG, n = 10). All participants underwent (i) a cardiopulmonary exercise test to determine their maximal oxygen uptake ([Formula: see text]) and (ii) a series of functional field tests (i.e., walking test, sit-to-stand test, and stair climbing test).

RESULTS

[Formula: see text]O₂max was 30% lower in PPSG than in CG and PG. Regarding functional field tests, walking and stair climbing test performances were significantly different among all groups. The PPSG sit-to-stand performance was lower than CG.

CONCLUSION

The sequelae of paralytic poliomyelitis impair functional exercise capacity obtained from maximal and submaximal tests, especially in patients with PPS. Furthermore, submaximal variables appear to be more negatively impacted than maximal variables.

Effects of specialist care lower limb orthoses on personal goal attainment and walking ability in adults with neuromuscular disorders

BACKGROUND

Lower limb orthoses intend to improve walking in adults with neuromuscular disorders (NMD). Yet, reported group effects of lower limb orthoses on treatment outcomes have generally been small and heterogeneous. We propose that guideline-based orthotic care within a multidisciplinary expert setting may improve treatment outcomes.

AIM

To examine the effectiveness of specialist care orthoses compared to usual care orthoses on personal goal attainment and walking ability.

DESIGN

Cohort study.

POPULATION

Adults with NMD who experienced walking problems due to calf and/or quadriceps muscle weakness and were provided with a specialist care lower limb orthosis between October 2011 and January 2021.

METHODS

Three months after provision, the specialist care orthosis was compared to the usual care orthosis worn at baseline in terms of personal goal attainment (Goal Attainment Scaling (GAS)), comfortable walking speed (m/s), net energy cost (J/kg/m) (both assessed during a 6-minute walk test), perceived walking ability and satisfaction.

RESULTS

Sixty-four adults with NMD were eligible for analysis. The specialist care orthoses comprised 19 dorsiflexion-restricting ankle-foot orthoses (AFOs), 22 stance-control knee-ankle-foot orthoses (KAFOs) and 23 locked KAFOs. Overall, 61% of subjects showed a clinically relevant improvement in GAS score. Perceived safety, stability, intensity, fear of falling and satisfaction while walking all improved (p≤0.002), and subjects were satisfied with their specialist care orthosis and the services provided. Although no effects on walking speed or net energy cost were found in combined orthosis groups, specialist care AFOs significantly reduced net energy cost (by 9.5%) compared to usual care orthoses (from mean (SD) 3.81 (0.97) to 3.45 (0.80) J/kg/m, p = 0.004).

CONCLUSION

Guideline-based orthotic care within a multidisciplinary expertise setting could improve treatment outcomes in adults with NMD compared to usual orthotic care by improvements in goal attainment and walking ability. A randomized controlled trial is now warranted to confirm these results.

Unexplained post-acute infection syndromes

SARS-CoV-2 is not unique in its ability to cause post-acute sequelae; certain acute infections have long been associated with an unexplained chronic disability in a minority of patients. These post-acute infection syndromes (PAISs) represent a substantial healthcare burden, but there is a lack of understanding of the underlying mechanisms, representing a significant blind spot in the field of medicine. The relatively similar symptom profiles of individual PAISs, irrespective of the infectious agent, as well as the overlap of clinical features with myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS), suggest the potential involvement of a common etiopathogenesis. In this Review, we summarize what is known about unexplained PAISs, provide context for post-acute sequelae of SARS-CoV-2 infection (PASC), and delineate the need for basic biomedical research into the underlying mechanisms behind this group of enigmatic chronic illnesses.

The effect of adding whole-body vibration exercises to home exercise program on muscle strength in patients with post-polio syndrome

Objectives

This study aims to understand the effectiveness of whole-body vibration (WBV) exercises performed with home exercise program in patients with post-polio syndrome (PPS) in terms of muscle strength, fatigue, the quality of life, and laboratory parameters.

Patients and methods

Between October 2015 and March 2016, a total of 14 patients (7 males, 7 females; mean age: 45.1±6.6 years; range, 34 to 57 years) who were diagnosed with PPS were included in the study. The patients were randomized into two groups: the first group received WBV, home exercise program and patient education while the second (control) group received home exercise program and patient education. The patients were evaluated by knee isometric and isokinetic peak torque, Fatigue Severity Scale (FSS), Fatigue Impact Scale (FIS), Nottingham Health Profile (NHP), serum creatine kinase, aspartate aminotransferase, and alanine aminotransferase at baseline and at the end of the treatment.

Results

At the end of the treatment, the exercise program administered to the patients was found to be effective in increasing knee muscle strength in PPS patients (p<0.05). This difference was more apparent on the sequela side, isometric extension peak torque in the group with WBV. There was no significant change in the markers of muscle damage or NHP in both groups.

Conclusion

Inclusion of WBV in home exercise program in PPS patients does not seem to be superior, except for reducing the effect of fatigue on the patient's life.

Energy cost optimized dorsal leaf ankle-foot-orthoses reduce impact forces on the contralateral leg in people with unilateral plantar flexor weakness

BACKGROUND

In individuals with unilateral plantar flexor weakness, the second peak of the vertical ground reaction force (GRF) is decreased. This leads to a higher ground reaction force, e.g. impact, of the contralateral leg, potentially explaining quadriceps muscle and/or knee joint pain. Energy cost optimized dorsal leaf ankle-foot-orthoses (AFOs) may increase the push-off ground reaction force, which in turn could lead to lower impact forces on the contralateral leg.

RESEARCH QUESTIONS

1) Are impact forces increased in the contralateral leg of people with unilateral plantar flexor weakness compared to healthy subjects? 2) Do energy cost optimized AFOs reduce impact forces and improve leg impact symmetry compared to walking without AFO in people with unilateral plantar flexor weakness?

METHODS

Nine subjects with unilateral plantar flexor weakness were provided a dorsal leaf AFO with a stiffness primarily optimized for energy cost. Using 3D gait analyses peak vertical GRF during loading response with and without AFO, and the symmetry between the legs in peak GRF were calculated. Peak GRF and symmetry were compared with reference data of 23 healthy subjects.

RESULTS

The contralateral leg showed a significant higher peak vertical GRF (12.0 ± 0.9 vs 11.2 ± 0.6 N/kg, p = 0.005) compared to healthy reference data. When walking with AFO, the peak vertical GRF of the contralateral leg significantly reduced (from 12.0 ± 0.9 to 11.4 ± 0.7 N/kg, p = 0.017) and symmetry improved compared to no AFO (from 0.93 ± 0.06 to 1.01 ± 0.05, p < 0.001).

CONCLUSION

In subjects with unilateral plantar flexor weakness, impact force on the contralateral leg was increased when compared to healthy subjects and dorsal leaf AFOs optimized for energy cost substantially reduced this force and improved impact symmetry when compared to walking without AFO. This indicates that dorsal leaf AFOs may reduce pain resulting from increased impact forces during gait in the contralateral leg in people with unilateral plantar flexor weakness.

Use and usability of custom-made knee-ankle-foot orthoses in polio survivors with knee instability: A cross-sectional survey

Objective

To investigate the use of custom-made knee-ankle-foot orthoses in daily life and differences in usability factors of knee-ankle-foot orthoses between users and discontinued users.

Design

Cross-sectional survey study.

Subjects

A total of 163 polio survivors provided with a knee-ankle-foot orthosis at an outpatient clinic of a university hospital.

Methods

Use and usability of knee-ankle-foot orthoses in daily life were assessed with a postal questionnaire. Usability factors were formulated using the International Organization for Standardization (ISO) 9241-11 standard.

Results

A total of 106 respondents (65%) returned the questionnaire. Of these, 98 were eligible for analysis. Seventy-four respondents (76%) reported using their knee-ankle-foot orthosis. Compared with discontinued users (24%), users experienced more limitations when walking without an orthosis (p = 0.001), were more often experienced with wearing a previous orthosis (p < 0.001) and were more often prescribed with a locked rather than a stance-control knee-ankle-foot orthosis (p = 0.015). Furthermore, users reported better effectiveness of their knee-ankle-foot orthosis (p < 0.001), more satisfaction with goals of use and knee-ankle-foot orthosis-related aspects (p < 0.001).

Conclusion

The majority of polio survivors used their custom-made knee-ankle-foot orthoses in daily life. Factors related to continued use, such as walking ability without orthosis, expectations of the orthosis, previous orthosis experience and type of knee-ankle-foot orthosis provided, should be considered and discussed when prescribing a knee-ankle-foot orthosis in polio survivors.

Polio survivors have poorer walking adaptability than healthy individuals

BACKGROUND

Falling is a major health problem in polio survivors, often occurring as a result of tripping, slipping or misplaced steps. Therefore, reduced walking adaptability possibly plays an important role.

RESEARCH QUESTION

Does walking adaptability, assessed on an interactive treadmill, differ between polio survivors and healthy individuals?

METHODS

In this cross-sectional study, 48 polio survivors with at least one reported fall in the past year and/or fear of falling and 25 healthy individuals of similar age walked at self-selected comfortable fixed speed on an instrumented treadmill. Walking adaptability was measured as i) target-stepping accuracy (determined as variable error [VE] in mm independent of speed) in three conditions; 0 %, 20 % and 30 % variation in step length and width, and ii) anticipatory and reactive obstacle avoidance (ObA and ObR, in percentage successfully avoided). All trials were checked for valid step detection.

RESULTS

46 polio survivors (mean ± SD age: 63.2 ± 8.7 years) and 25 healthy individuals (64.3 ± 6.6 years, p = 0.585) showed valid step detection. Compared to healthy individuals (mean±SE VE: 30.6±1.2 mm), polio survivors stepped less accurately onto targets (36.4±0.9 mm, p = 0.001), especially with their least-affected leg. Polio survivors avoided fewer obstacles successfully (mean±SE ObA: 83±3 %, ObR: 59±4 %) than healthy individuals (100±0.3 %, p < 0.001 and 94±3 %, p < 0.001, respectively), with a stronger decline in success rates from anticipatory to reactive obstacle avoidance for polio survivors (p < 0.001).

SIGNIFICANCE

Polio survivors reporting falls and/or fear of falling had a demonstrably reduced walking adaptability, especially so for reactive obstacle avoidance, which requires step adjustments under high time-pressure demands. Future research should study the merit of walking-adaptability assessment to currently used clinical methods of fall-risk assessment within this population.

Extra-motor manifestations in post-polio syndrome (PPS): fatigue, cognitive symptoms and radiological features

BACKGROUND

There is a paucity of cerebral neuroimaging studies in post-polio syndrome (PPS), despite the severity of neurological and neuropsychological sequelae associated with the condition. Fatigue, poor concentration, limited exercise tolerance, paraesthesia and progressive weakness are frequently reported, but the radiological underpinnings of these symptoms are poorly characterised.

OBJECTIVE

The aim of this study is to evaluate cortical and subcortical alterations in a cohort of adult polio survivors to explore the anatomical substrate of extra-motor manifestations.

METHODS

Thirty-six patients with post-polio syndrome, a disease-control group with amyotrophic lateral sclerosis patients and a cohort of healthy individuals were included in a prospective neuroimaging study with a standardised clinical and radiological protocol. Validated clinical instruments were utilised to assess mood, cognitive and behavioural domains and specific aspects of fatigue. Cortical thickness analyses, subcortical volumetry, brainstem segmentation and region-of-interest (ROI) white matter analyses were undertaken to assess regional grey and white matter alterations.

RESULTS

A high proportion of PPS patients exhibited apathy, verbal fluency deficits and reported self-perceived fatigue. On ROI analyses, cortical atrophy was limited to the cingulate gyrus, and the temporal pole and subcortical atrophy were only detected in the left nucleus accumbens. No FA reductions were noted to indicate white matter degeneration in any of the lobes.

CONCLUSIONS

Despite the high incidence of extra-motor manifestations in PPS, only limited cortical, subcortical and white matter degeneration was identified. Our findings suggest that non-structural causes, such as polypharmacy and poor sleep, may contribute to the complex symptomatology of post-polio syndrome.

A very long-term longitudinal follow-up of persons with late effects of polio

BACKGROUND

As many as 60-80% of persons with a history of polio myelitis develop new symptoms, such as new or increased muscle weakness, muscle and joint pain, and fatigue several decades later, called postpolio syndrome (PPS). This may affect their ability to perform activities of daily living (ADL). It is still unclear if the patient's symptom is getting worse and in that case how much/fast the decline is.

AIM

The aim of the present study was to evaluate long-term changes in disability in community dwelling patients with prior poliomyelitis, in contact with a polio clinic 14-16 years post their first assessment.

DESIGN

A cross sectional longitudinal study.

SETTING

Polio clinic.

POPULATION

Fifty-two persons recruited from an earlier 4-year follow-up participated in the study.

METHODS

A questionnaire was mailed prior to the visit at the polio clinic. Physical testing was performed by measuring muscle strength, walking speed and handgrip force.

RESULTS

Overall there was a small change in muscle strength. A significant reduction in the right leg was found for flexion 60° and in dorsal flexion. For the left leg a significant reduction was found for plantar flexion. In the walking tests, a significant reduction was seen for spontaneous walking speed. No significant interaction between decrease in spontaneous walking speed and the variables age, BMI and flexion 60° and dorsal flexion in the right leg was seen.

CONCLUSIONS

This cross-sectional longitudinal study shows small changes in muscle strength and disability. The results may imply that symptoms associated with late effects of polio are not progressing as fast as we had previously thought.

CLINICAL REHABILITATION IMPACT

When health care professionals meet persons with late effects of polio the knowledge of long-term consequences of deterioration is important. Knowing that the deterioration is not as fast as previously thought, can help us to support the person in having a healthy lifestyle, stay active and encourage to perform adapted physical training.

Modifying ankle foot orthosis stiffness in patients with calf muscle weakness: gait responses on group and individual level

Background

To improve gait, persons with calf muscle weakness can be provided with a dorsal leaf spring ankle foot orthosis (DLS-AFO). These AFOs can store energy during stance and return this energy during push-off, which, in turn, reduces walking energy cost. Simulations indicate that the effect of the DLS-AFO on walking energy cost and gait biomechanics depends on its stiffness and on patient characteristics. We therefore studied the effect of varying DLS-AFO stiffness on reducing walking energy cost, and improving gait biomechanics and AFO generated power in persons with non-spastic calf muscle weakness, and whether the optimal AFO stiffness for maximally reducing walking energy cost varies between persons.

Methods

Thirty-seven individuals with neuromuscular disorders and non-spastic calf muscle weakness were included. Participants were provided with a DLS-AFO of which the stiffness could be varied. For 5 stiffness configurations (ranging from 2.8 to 6.6 Nm/degree), walking energy cost (J/kg/m) was assessed using a 6-min comfortable walk test. Selected gait parameters, e.g. maximal dorsiflexion angle, ankle power, knee angle, knee moment and AFO generated power, were derived from 3D gait analysis.

Results

On group level, no significant effect of DLS-AFO stiffness on reducing walking energy cost was found (p = 0.059, largest difference: 0.14 J/kg/m). The AFO stiffness that reduced energy cost the most varied between persons. The difference in energy cost between the least and most efficient AFO stiffness was on average 10.7%. Regarding gait biomechanics, increasing AFO stiffness significantly decreased maximal ankle dorsiflexion angle (− 1.1 ± 0.1 degrees per 1 Nm/degree, p < 0.001) and peak ankle power (− 0.09 ± 0.01 W/kg, p < 0.001). The reduction in minimal knee angle (− 0.3 ± 0.1 degrees, p = 0.034), and increment in external knee extension moment in stance (− 0.01 ± 0.01 Nm/kg, p = 0.016) were small, although all stiffness’ substantially affected knee angle and knee moment compared to shoes only. No effect of stiffness on AFO generated power was found (p = 0.900).

Conclusions

The optimal efficient DLS-AFO stiffness varied largely between persons with non-spastic calf muscle weakness. Results indicate this is caused by an individual trade-off between ankle angle and ankle power affected differently by AFO stiffness. We therefore recommend that the AFO stiffness should be individually optimized to best improve gait.

Trial registration number

Nederlands Trial Register 5170. Registration date: May 7th 2015. http://www.trialregister.nl/trialreg/admin/rctview.asp?TC=5170

Poliomyelitis

Poliomyelitis, often termed "polio," is an acute infectious disease caused by an enterovirus which damages the anterior horn cells of the spinal cord and brainstem. Progress to lower motor neurone cell death leads to disruption of motor units and subsequent muscle weakness or complete paralysis. Although the virus is mostly eradicated from the Western world, postpolio decline is prevalent among people aged 60 years and over. It is characterized primarily by fatigability and muscle weakness, but pain is also common. Reductions in lower-limb muscle strength, voluntary drive, and endurance are likely to contribute to the impaired balance control, slow gait, and dysfunctional lower-limb kinematics reported in polio survivors. Given these significant risk factors, polio survivors fall up to four times more often than their age-matched healthy peers. Interventions to improve function, reduce disability, and prevent falls in polio survivors are therefore clinically relevant but studies are lacking, limiting the evidence base. Balance training, cognitive behavioral therapy, and orthoses prescription might be recommended. Muscle-strengthening programs should be carefully designed and delivered due to their potential detrimental effects related to excessive use and potential dysfunction of motor neurones and their axons.

Gait patterns in association with underlying impairments in polio survivors with calf muscle weakness

The objective was to identify gait patterns in polio survivors with calf muscle weakness and associate them to underlying lower extremity impairments, which are expected to help in the search for an optimal orthosis. Unilaterally affected patients underwent barefoot 3D-gait analyses. Gait pattern clusters were created based on the ankle and knee angle and ankle moment shown in midstance of the affected limb. Impairment clusters were created based on plantarflexor and knee-extensor strength, and ankle and knee joint range-of-motion. The association between gait patterns and underlying impairments were examined descriptively. The Random Forest Algorithm and regression analyses were used to predict gait patterns and parameters. Seven gait patterns in 73 polio survivors were identified, with two dominant patterns: one with a mildly/non-deviant ankle angle, ankle moment and knee angle (n=23), and one with a strongly deviant ankle angle and a mildly/non-deviant ankle moment and knee angle (n=18). Gait pattern prediction from underlying impairments was 49% accurate with best prediction performance for the second dominant gait pattern (sensitivity 78% and positive predictive value 74%). The underlying impairments explained between 20 and 32% of the variance in individual gait parameters. Polio survivors with calf muscle weakness who present a similar impairment profile do not necessarily walk the same. From physical examination alone, the gait pattern nor the individual gait parameters could be accurately predicted. The patient's gait should therefore be measured to help in the prescription and evaluation of orthoses for these patients.

Precision orthotics: optimising ankle foot orthoses to improve gait in patients with neuromuscular diseases; protocol of the PROOF-AFO study, a prospective intervention study

INTRODUCTION

In patients with neuromuscular disorders and subsequent calf muscle weakness, metabolic walking energy cost (EC) is nearly always increased, which may restrict walking activity in daily life. To reduce walking EC, a spring-like ankle-foot-orthosis (AFO) can be prescribed. However, the reduction in EC that can be obtained from these AFOs is stiffness dependent, and it is unknown which AFO stiffness would optimally support calf muscle weakness. The PROOF-AFO study aims to determine the effectiveness of stiffness-optimised AFOs on reducing walking EC, and improving gait biomechanics and walking speed in patients with calf muscle weakness, compared to standard, non-optimised AFOs. A second aim is to build a model to predict optimal AFO stiffness.

METHODS AND ANALYSIS

A prospective intervention study will be conducted. In total, 37 patients with calf muscle weakness who already use an AFO will be recruited. At study entry, participants will receive a new custom-made spring-like AFO of which the stiffness can be varied. For each patient, walking EC (primary outcome), gait biomechanics and walking speed (secondary outcomes) will be assessed for five stiffness configurations and the patient's own (standard) AFO. On the basis of walking EC and gait biomechanics outcomes, the optimal AFO stiffness will be determined. After wearing this optimal AFO for 3 months, walking EC, gait biomechanics and walking speed will be assessed again and compared to the standard AFO.

ETHICS AND DISSEMINATION

The Medical Ethics Committee of the Academic Medical Centre in Amsterdam has approved the study protocol. The study is registered at the Dutch trial register (NTR 5170). The PROOF-AFO study is the first to compare stiffness-optimised AFOs with usual care AFOs in patients with calf muscle weakness. The results will also provide insight into factors that influence optimal AFO stiffness in these patients. The results are necessary for improving orthotic treatment and will be disseminated through international peer-reviewed journals and scientific conferences.

Health related quality of life in Turkish polio survivors: impact of post-polio on the health related quality of life in terms of functional status, severity of pain, fatigue, and social, and emotional functioning

OBJECTIVE

To determine the impact of postpolio-syndrome on quality of life in polio survivors.

METHODS

Forty polio survivors were included in the study. Twenty-one patients fulfilling the Halstead's postpolio-syndrome criteria participated in postpolio-syndrome group. The remaining nineteen patients formed non-postpolio-syndrome group. Control group was composed of forty healthy subjects. Quality of life was evaluated by Nottingham Health Profile, depression by Beck Depression Scale and fatigue by Fatigue Symptom Inventory. Isometric muscle strength was measured by manual muscle testing.

RESULTS

Total manual muscle testing score was 26.19±13.24 (median: 29) in postpolio-syndrome group and 30.08±8.9 (median: 32) in non-postpolio-syndrome group. Total manual muscle testing scores of non-postpolio-syndrome group were significantly higher than that of postpolio-syndrome group. Patients with postpolio-syndrome reported significantly higher levels of fatigue and reduced quality of life in terms of physical mobility, pain and energy when compared with patients without postpolio-syndrome and control group. It was not reported a statistically significant difference in social and emotional functioning and sleep quality between postpolio-syndrome, non-postpolio-syndrome and control groups. Also it was not found any statistically significant difference in Beck Depression Scale scores among the groups.

CONCLUSIONS

Postpolio-syndrome has a negative impact on quality of life in terms of functional status, severity of pain and energy. The identification, early recognition and rehabilitation of postpolio-syndrome patients may result in an improvement in their quality of life.

Disabilities and Health

The authors believe that a coordinated national agenda on health and wellness research regarding persons with disabilities that (a) focuses disparate national efforts and (b) advances a unified holistic model is needed. They propose a framework for such an agenda that includes five core principles and six issue areas, with recommendations. The five principles address good health as a normative expectation, a theory-driven knowledge base, heterogeneity of the disability experience, translation of research to practice, and coordinated research. Funding entities, scientific researchers, and disability communities must begin working with an integrated conceptualization of disability; facilitating diagnostic-specific and cross-disability research; recognizing diversity within the disability population; promoting opportunity, accessibility, and accountability; prioritizing application of research into practice; and coordinating research agendas among funding entities. It concludes with identifying key responsibilities for funding entities, researchers, and disability advocacy organizations and persons with disabilities.

The effects of a home-based arm ergometry exercise programme on physical fitness, fatigue and activity in Polio survivors: a randomised controlled trial

Objective:

To investigate the effect of an eight-week home-based arm ergometry aerobic exercise programme on physical fitness, fatigue, activity and quality of life in Polio Survivors.

Design:

An assessor blinded randomised controlled trial.

Setting:

Home-based exercise.

Subjects:

Fifty-five Polio survivors randomised to exercise or control groups.

Intervention:

Home-based arm ergometry at an intensity of 50%-70% maximum heart rate, compared with usual physiotherapy care.

Main measures:

The Six-minute Arm Test, Fatigue Severity Scale, Physical Activity Scale for Individuals with Physical Disabilities and SF-36. Assessments were completed at baseline and at eight weeks.

Results:

There was no significant difference in the primary outcome, exercising heart rate during the Six-minute Arm Test, between the groups at follow-up [97.6 (SD10.1) compared to 102.4 (SD13.7) beats per minute ( P=0.20)]. Blood pressure was significantly lower in the intervention group at follow-up [systolic blood pressure 132(18.6)mmHg compared to 144.1(14.6)mmHg ( P=0.002)]. There were no between group differences in the Fatigue Severity Scale ( P=0.25) or Physical Activity Scale for Individuals with Physical Disabilities ( P=0.49), with a small difference in SF-36 physical component score ( P=0.04).

Conclusions:

This home-based arm ergometry programme successfully facilitated aerobic exercise in Polio Survivors, but did not result in a significant change in physical fitness, measured by the Six-minute Arm Test.

Aerobic Exercise Training in Post-Polio Syndrome: Process Evaluation of a Randomized Controlled Trial

Objective

To explore reasons for the lack of efficacy of a high intensity aerobic exercise program in post-polio syndrome (PPS) on cardiorespiratory fitness by evaluating adherence to the training program and effects on muscle function.

Design

A process evaluation using data from an RCT.

Patients

Forty-four severely fatigued individuals with PPS were randomized to exercise therapy (n = 22) or usual care (n = 22).

Methods

Participants in the exercise group were instructed to exercise 3 times weekly for 4 months on a bicycle ergometer (60–70% heart rate reserve).

Results

The attendance rate was high (median 89%). None of the participants trained within the target heart rate range during >75% of the designated time. Instead, participants exercised at lower intensities, though still around the anaerobic threshold (AT) most of the time. Muscle function did not improve in the exercise group.

Conclusion

Our results suggest that severely fatigued individuals with PPS cannot adhere to a high intensity aerobic exercise program on a cycle ergometer. Despite exercise intensities around the AT, lower extremity muscle function nor cardiorespiratory fitness improved. Improving the aerobic capacity in PPS is difficult through exercise primarily focusing on the lower extremities, and may require a more individualized approach, including the use of other large muscle groups instead.

Trial Registration

Netherlands National Trial Register NTR1371

Experiences and perspectives of patients with post-polio syndrome and therapists with exercise and cognitive behavioural therapy

Background

Many persons affected with poliomyelitis develop post-polio syndrome (PPS) later in their life. Recently, the effectiveness of Exercise Therapy (ET) and Cognitive Behavioural Therapy (CBT) for PPS has been evaluated in a randomized controlled trial, but did not show a decrease in fatigue or improvement in secondary endpoints like Quality of Life and self-perceived activity limitations. The aim of this explorative study was to gain insight in the perceived effects and experiences of the interventions from the perspectives of the patients and therapists.

Methods

Qualitative data were collected through semi-structured interviews with 17 patients and 7 therapists. All participants were involved in the trial. A thematic analysis of the data was performed.

Results

Some patients experienced a short term enhanced endurance and a better use of energy during the day. However, in general patients did not experience a long lasting reduction of fatigue from the CBT or ET. Mainly patients of the CBT, but also some patients of the ET described an increase of self-esteem and self-acceptance. As a result, patients were sometimes better able to perform physical activities during the day. In contrast to the CBT, the ET was in general perceived by the patients as an intensive therapy, which was difficult to fit into their daily routine. Therapists of both the CBT and the ET struggled with a low intrinsic motivation of the patients in the study. This made it sometimes difficult for the therapists to follow the protocol.

Conclusion

Confirming the negative quantitative study outcome, the qualitative results did not demonstrate lasting effects on fatigue. Patients did, however, experience some benefits on self-esteem and acceptance of the disease. This study showed that it is of great importance to work with feasible interventions; they should fit the patients’ needs on a practical (fit into their daily routine) and mental (fit their need for support) level.

A randomized controlled trial of coenzyme Q10 for fatigue in the late-onset sequelae of poliomyelitis

OBJECTIVE

To determine if coenzyme Q(10) alleviates fatigue in the late-onset sequelae of poliomyelitis.

DESIGN

Parallel-group, randomized, placebo-controlled trial.

BACKGROUND SETTING

Coenzyme Q(10) has been shown to boost muscle energy metabolism in post-polio subjects but it does not promote muscle strength, endurance or function in polio survivors with post-poliomyelitis syndrome. However, the collective increased energy metabolism might contribute to a reduction in post-polio fatigue.

PARTICIPANTS

Polio survivors from the Australian post-polio networks in Queensland and New South Wales who attribute a moderate to high level of fatigue to their diagnosed late-onset sequelae of poliomyelitis. Those with fatigue-associated comorbidities of diabetes, anaemia, hypothyroidism and fibromyalgia were excluded.

METHOD

Participants were assigned (1:1), with stratification of those who use energy-saving mobility aids, to receive 100 mg coenzyme Q(10) or matching placebo daily for 60 days. Participants and investigators were blinded to group allocation. Fatigue was assessed by the Multidimensional Assessment of Fatigue as the primary outcome and the Fatigue Severity Scale as secondary outcome.

RESULTS

Of 103 participants, 54 were assigned to receive coenzyme Q(10) and 49 to receive the placebo. The difference in the mean score reductions between the two groups was not statistically significant for either fatigue measure. Oral supplementation with coenzyme Q(10) was safe and well-tolerated.

CONCLUSION

A daily dose of 100 mg coenzyme Q(10) for 60 days does not alleviate the fatigue of the late-onset sequelae of poliomyelitis. The registration number for the clinical trial is ACTRN 12612000552886.

No Reduction of Severe Fatigue in Patients With Postpolio Syndrome by Exercise Therapy or Cognitive Behavioral Therapy

Background. People with postpolio syndrome (PPS) commonly experience severe fatigue that persists over time and negatively affects functioning and health-related quality of life (HRQoL). Objectives. To study the efficacy of exercise therapy (ET) and cognitive behavioral therapy (CBT) on reducing fatigue and improving activities and HRQoL in patients with PPS. Methods. We conducted a multicenter, single-blinded, randomized controlled trial. Over 4 months, severely fatigued patients with PPS received ET, CBT, or usual care (UC). The primary end point (fatigue) was assessed using the subscale fatigue severity of the Checklist Individual Strength (CIS20-F). Secondary end points included activities and HRQoL, which were assessed with the Sickness Impact Profile and the 36-Item Short-Form, respectively. End points were measured at baseline and at 4, 7, and 10 months. Results. A total of 68 patients were randomized. No differences were observed between the intervention groups and UC group for fatigue (mean differences in CIS20-F score = 1.47, 95%CI = −2.84 to 5.79, for ET versus UC; and 1.87, 95%CI = −2.24 to 5.98, for CBT versus UC), activities, or HRQoL. Conclusions. Our results demonstrate that neither ET nor CBT were superior to UC in reducing fatigue in severely fatigued PPS patients. Further research should investigate explanations for the lack of efficacy of these 2 currently advised approaches in clinical practice, which may provide clues to improving treatment aimed at reducing fatigue in PPS.

Factors Associated with Reduced Quality of Life in Polio Survivors in Korea

The purpose of this study is to assess health-related quality of life in polio survivors (PS) compared with that in the general population in Korea. Polio survivors (n = 120) from outpatient clinics at two hospitals, healthy controls (HC, n = 121) and members of the general population with activity limitations (AL, n = 121) recruited through a proportional-allocation, systematic sampling strategy from the Fourth Korean National Health and Nutrition Examination Survey were surveyed with self-rated health-related quality of life (Euro QoL five-dimensions). The proportion of participants who reported problems in mobility, usual activity, and symptoms of anxiety/depression were higher in the PS group compared with the HC and AL groups. There was no significant difference in the self-care dimension across the groups. Polio-specific questionnaire, pain, depression, fatigue, Modified Barthel Index (K-MBI) and Short Physical Performance Battery (SPPB) were assessed in the PS group. Those with post-poliomyelitis syndrome had greater problems in mobility, usual activity, and depression/anxiety. Polio survivors, especially those with more pain and fatigue symptoms, and those who did not have access to medical services had poorer health-related quality of life. These findings afford useful information for potential intervention improving quality of life in polio survivors.

Treatment for postpolio syndrome

BACKGROUND

Postpolio syndrome (PPS) may affect survivors of paralytic poliomyelitis and is characterised by a complex of neuromuscular symptoms leading to a decline in physical functioning. The effectiveness of pharmacological treatment and rehabilitation management in PPS is not yet established. This is an update of a review first published in 2011.

OBJECTIVES

To systematically review the evidence from randomised and quasi-randomised controlled trials for the effect of any pharmacological or non-pharmacological treatment for PPS compared to placebo, usual care or no treatment. 

SEARCH METHODS

We searched the following databases on 21 July 2014: Cochrane Neuromuscular Disease Group Specialized Register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, PsycINFO and CINAHL Plus. We also checked reference lists of all relevant articles, searched the Database of Abstracts of Reviews of Effects (DARE), the Health Technology Assessment (HTA) Database and trial registers and contacted investigators known to be involved in research in this area.

SELECTION CRITERIA

Randomised and quasi-randomised trials of any form of pharmacological or non-pharmacological treatment for people with PPS. The primary outcome was self perceived activity limitations and secondary outcomes were muscle strength, muscle endurance, fatigue, pain and adverse events.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by The Cochrane Collaboration.

MAIN RESULTS

We included 10 pharmacological (modafinil, intravenous immunoglobulin (IVIg), pyridostigmine, lamotrigine, amantadine, prednisone) and three non-pharmacological (muscle strengthening, rehabilitation in a warm climate (that is temperature ± 25°C, dry and sunny) and a cold climate (that is temperature ± 0°C, rainy or snowy), static magnetic fields) studies with a total of 675 participants with PPS in this review. None of the included studies were completely free from any risk of bias, the most prevalent risk of bias being lack of blinding.There was moderate- and low-quality evidence that IVIg has no beneficial effect on activity limitations in the short term and long term, respectively, and inconsistency in the evidence for effectiveness on muscle strength. IVIg caused minor adverse events in a substantial proportion of the participants. Results of one trial provided very low-quality evidence that lamotrigine might be effective in reducing pain and fatigue, resulting in fewer activity limitations without generating adverse events. Data from two single trials suggested that muscle strengthening of thumb muscles (very low-quality evidence) and static magnetic fields (moderate-quality evidence) are safe and beneficial for improving muscle strength and pain, respectively, with unknown effects on activity limitations. Finally, there was evidence varying from very low quality to high quality that modafinil, pyridostigmine, amantadine, prednisone and rehabilitation in a warm or cold climate are not beneficial in PPS.

AUTHORS' CONCLUSIONS

Due to insufficient good-quality data and lack of randomised studies, it was impossible to draw definite conclusions about the effectiveness of interventions for PPS. Results indicated that IVIg, lamotrigine, muscle strengthening exercises and static magnetic fields may be beneficial but need further investigation to clarify whether any real and meaningful effect exists.

Does a subgroup of postpolio patients need different management?

Throughout the 30 years of postpolio syndrome (PPS) research, there have been many puzzling anomalies in the data and not enough information to make sense of them. It is therefore welcome that Winberg et al have examined physical activity in relation to life satisfaction, sex and age. They hypothesized that activity would decrease with age and found the opposite. This result is not so surprising as Ostlund et al found that vitality was associated with older age and that younger age was associated with more pain, increasing physical fatigue, decreasing sleep quality and reducing activity. This commentary will examine past postpolio research with unexpected results in order to describe a subgroup of patients who may be more susceptible to overusing muscles and have particular exercise and activity needs.

[Health related quality of life in Turkish polio survivors: impact of post-polio on the health related quality of life in terms of functional status, severity of pain, fatigue, and social, and emotional functioning]

OBJECTIVE

To determine the impact of postpolio-syndrome on quality of life in polio survivors.

METHODS

Forty polio survivors were included in the study. Twenty-one patients fulfilling the Halstead's postpolio-syndrome criteria participated in postpolio-syndrome group. The remaining nineteen patients formed non-postpolio-syndrome group. Control group was composed of forty healthy subjects. Quality of life was evaluated by Nottingham Health Profile, depression by Beck Depression Scale and fatigue by Fatigue Symptom Inventory. Isometric muscle strength was measured by manual muscle testing.

RESULTS

Total manual muscle testing score was 26.19±13.24 (median: 29) in postpolio-syndrome group and 30.08±8.9 (median: 32) in non-postpolio-syndrome group. Total manual muscle testing scores of non-postpolio-syndrome group were significantly higher than that of postpolio-syndrome group. Patients with postpolio-syndrome reported significantly higher levels of fatigue and reduced quality of life in terms of physical mobility, pain and energy when compared with patients without postpolio-syndrome and control group. It was not reported a statistically significant difference in social and emotional functioning and sleep quality between postpolio-syndrome, non-postpolio-syndrome and control groups. Also it was not found any statistically significant difference in Beck Depression Scale scores among the groups.

CONCLUSIONS

Postpolio-syndrome has a negative impact on quality of life in terms of functional status, severity of pain and energy. The identification, early recognition and rehabilitation of postpolio-syndrome patients may result in an improvement in their quality of life.

Reliability of contractile properties of the knee extensor muscles in individuals with post-polio syndrome

Objective

To assess the reliability of contractile properties of the knee extensor muscles in 23 individuals with post-polio syndrome (PPS) and 18 age-matched healthy individuals.

Methods

Contractile properties of the knee extensors were assessed from repeated electrically evoked contractions on 2 separate days, with the use of a fixed dynamometer. Reliability was determined for fatigue resistance, rate of torque development (MRTD), and early and late relaxation time (RT50 and RT25), using the intraclass correlation coefficient (ICC) and standard error of measurement (SEM, expressed as % of the mean).

Results

In both groups, reliability for fatigue resistance was good, with high ICCs (>0.90) and small SEM values (PPS: 7.1%, healthy individuals: 7.0%). Reliability for contractile speed indices varied, with the best values found for RT50 (ICCs>0.82, SEM values <2.8%). We found no systematic differences between test and retest occasions, except for RT50 in healthy subjects (p = 0.016).

Conclusions

In PPS and healthy individuals, the reliability of fatigue resistance, as obtained from electrically evoked contractions is high. The reliability of contractile speed is only moderate, except for RT50 in PPS, demonstrating high reliability.

Significance

This was the first study to examine the reliability of electrically evoked contractile properties in individuals with PPS. Our results demonstrate its potential to study mechanisms underlying muscle fatigue in PPS and to evaluate changes in contractile properties over time in response to interventions or from natural course.

Ankle-foot orthoses that restrict dorsiflexion improve walking in polio survivors with calf muscle weakness

In polio survivors with calf muscle weakness, dorsiflexion-restricting ankle-foot orthoses (DR-AFOs) aim to improve gait in order to reduce walking-related problems such as instability or increased energy cost. However, evidence on the efficacy of DR-AFOs in polio survivors is lacking. We investigated the effect of DR-AFOs on gait biomechanics, walking energy cost, speed, and perceived waking ability in this patient group. Sixteen polio survivors with calf muscle weakness underwent 3D-gait analyses to assess gait biomechanics when walking with a DR-AFOs and with shoes only. Ambulant registration of gas-exchange during a 6 min walk test determined walking energy cost, and comfortable gait speed was calculated from the walked distance during this test. Perceived walking ability was assessed using purposely-designed questionnaires. Compared with shoes-only, walking with the DR-AFOs significantly increased forward progression of the center of pressure (CoP) in mid-stance and it reduced ankle dorsiflexion and knee flexion in mid- and terminal stance (p < 0.05). Furthermore, walking energy cost was lower (-7%, p = 0.052) and gait speed was higher (p = 0.005). Patients were significantly more satisfied, felt safer, and less exhausted with the DR-AFO, compared to shoes-only (p < 0.05). DR-AFO effects varied largely across patients. Patients who walked with limited forward CoP progression and persisting knee extension during the shoes-only condition seemed to have benefitted least from the DR-AFO. In polio survivors with calf muscle weakness, DR-AFOs improved gait biomechanics, speed, and perceived walking ability, compared to shoes-only. Effects may depend on the shoes-only gait pattern, therefore further study is needed to determine which patients benefit most from the DR-AFO.

Assessment of subjective and motor fatigue in Polio survivors, attending a Postpolio clinic, comparison with healthy controls and an exploration of clinical correlates

PURPOSE

Polio survivors experience declining mobility, pain and fatigue. The extent of motor fatigue and its impact on mobility and quality of life, in addition to other commonly reported impairments requires evaluation.

METHODS

An observational, case-control, cross-sectional design was used to assess 30 Polio survivors and 30 age- and sex-matched controls. Muscle strength and motor fatigue were assessed using fixed dynamometry. Fatigue, pain and quality of life were assessed using the Piper Fatigue Scale, the Fatigue Severity Scale, visual analogue scales and the RAND Short Form-36, respectively. An 8-min walking test, including physiological cost index (PCI), evaluated mobility.

RESULTS

A significant difference in motor fatigue was identified only in hand grip (p = 0.03). Polio survivors were significantly weaker (p < 0.001) and more fatigued (p < 0.001) than controls. Motor fatigue was not related to subjective fatigue, mobility or quality of life. Muscle strength predicted mobility. Pain and fatigue were associated with lower mental quality of life, while PCI was associated with physical quality of life.

CONCLUSION

Motor fatigue has been identified in Polio survivors but was only significantly different in hand grip, using this approach. Pain, fatigue and elevated energy cost of walking negatively influenced quality of life. Motor fatigue was unrelated to subjective fatigue, mobility or quality of life.

Knowledge among physical education professionals about poliomyelitis and post-poliomyelitis syndrome: a cross-sectional study in Brazil

BACKGROUND

Post-poliomyelitis syndrome is a clinical condition that can affect poliomyelitis survivors with the onset of new symptoms several years after the acute disease. These symptoms include new muscular weakness, fatigue, pain, onset or aggravation of muscle atrophy, muscle cramps, onset or aggravation of pre-existing difficulties in accomplishing daily life activities, cold intolerance, sleep disorders, dysphonia or dysphagia, and respiratory deficiency. The treatment of post-poliomyelitis syndrome requires a multiprofessional health team because the rehabilitation procedures include lifestyle changes, physiotherapy, avoidance of secondary complications, and physical exercise. As physical exercise is prescribed by physical education professionals, the assessment of knowledge about post-poliomyelitis syndrome among these professionals is very relevant. The aim of this study was to evaluate poliomyelitis and post-poliomyelitis syndrome knowledge among physical education professionals in Brazil.

METHODS

We invited participants with an academic degree in physical education (n = 217) to participate in this study. A self-administered survey (30 questions) was designed to probe knowledge about poliomyelitis and post-poliomyelitis syndrome. From the survey, we created a questionnaire to evaluate the performance of the professionals. The questionnaire was composed of 20 questions and a score was provided, varying from 0 (totally uninformed) to 20 (well informed).

RESULTS

Approximately 73% of surveyed participants had never heard of post-poliomyelitis syndrome, and only 19.4% had received information about the disease. Among those surveyed, 61.8% did not know whether restriction of physical activities was warranted for people with poliomyelitis sequelae, and only 32.3% knew that physical exercise (especially intense exercise) should be limited for patients with sequelae of paralytic poliomyelitis.

CONCLUSION

The findings of the present study indicate a critical need for improvement of knowledge about post-poliomyelitis syndrome among Brazilian physical education professionals.

Exercise in neuromuscular disease

In this review, we present an overview of the role of exercise in neuromuscular disease (NMD). We demonstrate that despite the different pathologies in NMDs, exercise is beneficial, whether aerobic/endurance or strength/resistive training, and we explore whether this benefit has a similar mechanism to that of healthy subjects. We discuss further areas for study, incorporating imaginative and novel approaches to training and its assessment in NMD. We conclude by suggesting ways to improve future trials by avoiding previous methodological flaws and drawbacks in this field.

Severe fatigue and reduced quality of life in children with hereditary motor and sensory neuropathy 1A

Severe fatigue and low quality of life are reported by a majority of adult patients with hereditary motor and sensory neuropathy 1A. In children with hereditary motor and sensory neuropathy 1A, the prevalence and impact of fatigue have not been studied yet. In this questionnaire survey, 55 Dutch children (response rate 77%) with genetically confirmed hereditary motor and sensory neuropathy 1A participated (mean age 15 years [standard deviation 2.1]). Prevalence of severe fatigue (based on a cut-off score of the Checklist Individual Strength) was 24%, in contrast to 14% in a Dutch school-based population (P < .05). Almost all quality-of-life scores (measured with the Child Health Questionnaire-Child Form 87) were significantly worse than population norms (P < .05). Fatigue severity was associated significantly (P < .01) with all quality-of-life scores (-0.4 < r < -0.7). In conclusion, severe fatigue and diminished quality of life are more frequent among children with hereditary motor and sensory neuropathy 1A compared to healthy peers. The strong association between fatigue severity and quality of life suggests a negative impact of fatigue on quality of life in these children.

Chronic pain, fatigue, and depressive symptoms in adults with spastic bilateral cerebral palsy

AIM

To investigate the prevalence and co-occurrence of chronic pain, fatigue, and depressive symptoms in adults with spastic bilateral cerebral palsy (SBCP) and explore associations of chronic pain and fatigue with depressive symptoms and daily functioning.

METHOD

Fifty-six adults with SBCP without severe cognitive impairment participated (35 males, 21 females; mean age 36y 5mo, SD 5y 10mo; Gross Motor Function Classification System level I [13], II [28], III [11], IV [4]). Chronic pain (>3mo), severity and nature of fatigue (Fatigue Severity Scale; Multidimensional Fatigue Inventory), and depressive symptoms (Center for Epidemiological Studies Depression Scale) were assessed. Associations were explored using multivariable logistic regression analyses.

RESULTS

The study sample had a higher prevalence of chronic pain (75% vs 39%; p<0.001), mean fatigue (Fatigue Severity Scale, 4.4 [SD 1.3] vs 2.9 [SD 1.1]; p<0.001), and prevalence of depressive symptoms (25% vs 12%; p=0.004) than Dutch healthy reference samples. Chronic pain and severe fatigue co-occurred in 34% and in combination with depressive symptoms in 16% of the participants. Severity of fatigue was associated with depressive symptoms (OR 3.38; p<0.01). Chronic pain and fatigue were not associated with limitations in daily functioning.

INTERPRETATION

These findings suggest that adults with SBCP are severely affected by chronic pain, fatigue, and depressive symptoms, in addition to their spastic paresis.

WOMAC-pf as a measure of physical function in patients with Parkinson's disease and late-onset sequels of poliomyelitis: unidimensionality and item behaviour

PURPOSE

To assess psychometric properties of the Western Ontario and MacMasters Universities Osteoarthritis Index (WOMAC)-pf, an osteoarthritis (OA)-specific questionnaire used to establish the level of physical functioning in patients with late-onset sequels of poliomyelitis (LOSP) and Parkinson's disease (PD).

STUDY DESIGN AND SETTING

Unidimensionality (using principal component analyses [PCA] and Rasch analyses) was separately established for three diagnostic groups: OA (n = 288), LOSP (n = 168) and PD (n = 200). Additionally, differential item functioning (DIF) among the three diagnostic groups was assessed using ordinal regression (Polytomous Universal Model) analyses. Baseline data were used from an ongoing cohort study of these three patient populations.

RESULTS

Unidimensionality was adequate, with all items loading on the first principal component. The Rasch analyses revealed that item fit was generally good. Uniform and non-uniform DIF were found to be present among the three diagnostic groups in three and one of the 17 physical functioning subscale (WOMAC-pf) items, respectively.

CONCLUSION

The WOMAC-pf is a unidimensional measure of physical functioning in patients with LOSP and PD, in addition to its established use in OA. [

IMPLICATIONS FOR REHABILITATION

• Disability in physical functioning related to mobility(walking, stair climbing, etc.) is a common feature of many chronic diseases, including osteoarthritis, late-onset sequels of poliomyelitis and Parkinson's disease.• In this study, the Western Ontario and MacMasters Universities Osteoarthritis Index-pf was shown to bea useful and adequate tool to assess physical functioning in these patient groups.• The study highlighted that, despite differences in diagnosis,history and course of the disease, patients with different conditions experience similar disabilities in their physical functioning.]

A candidate core set of outcome measures based on the International Classification of Functioning, Disability and Health for clinical studies on lower limb orthoses

BACKGROUND

Although many core sets of measurement concepts have been published in the literature, this has not been done for the field of lower limb orthoses.

OBJECTIVES

This paper provides an overview of the measurement concepts that are relevant in lower limb orthotic evaluations, and it proposes a candidate Core Set of outcome measures to be used in clinical studies on ankle-foot orthoses (AFOs) and knee-ankle-foot orthoses (KAFOs).

STUDY DESIGN

Literature review.

METHODS

The International Classification of Functioning, Disability and Health (ICF) was used as framework to select relevant concepts.

RESULTS AND CONCLUSION

Measurement concepts covering all ICF levels of functioning were identified as relevant for the Core Set, including functions of the joints and bones (b710-b729), muscle functions (b730-b749), gait pattern functions (b770), walking (b450), moving around in different locations (d460), and daily-life functioning (d5-d9). Further validation of this candidate Core Set through a formal decision-making process is needed to obtain consensus among experts in the field. Based on such a consensus, the next step will be to systematically review the literature and identify those measurement instruments that are best suited to assess the proposed concepts, based on their psychometric properties in a given sample and context. Thereafter, we suggest that this ICF Core Set of measurement instruments should be applied in orthotic studies on AFOs and KAFOs in ambulatory patients with gait problems.

CLINICAL RELEVANCE

Although many ICF Core Sets have been published, this has not been done for the field of lower limb orthoses. We feel that such a Core Set is urgently needed, to enable comparison of results, and establish evidence on the efficacy of orthotic treatment, which will improve patient care.

Treatment for postpolio syndrome

BACKGROUND

Postpolio syndrome (PPS) may affect survivors of paralytic poliomyelitis and is characterised by a complex of neuromuscular symptoms leading to a decline in physical functioning. The effectiveness of pharmacological treatment and rehabilitation management in PPS is not yet established.

OBJECTIVES

To review systematically the effects of any treatment for PPS compared to placebo, usual care or no treatment.  

SEARCH STRATEGY

We searched the following databases on 1 October 2010: Cochrane Neuromuscular Disease Group Specialized Register, the Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, PsycINFO and CINAHL Plus from inception to September 2010.

SELECTION CRITERIA

Randomised and quasi-randomised trials of any form of pharmacological or non-pharmacological treatment for people with PPS. The primary outcome was self-perceived activity limitations and secondary outcomes were muscle strength, muscle endurance, fatigue, pain and adverse events.

DATA COLLECTION AND ANALYSIS

Two authors independently selected eligible studies, assessed risk of bias and extracted data.

MAIN RESULTS

Nine pharmacological (modafinil, intravenous immunoglobulin, pyridostigmine, lamotrigine, amantadine, prednisone) and three non-pharmacological (muscle strengthening, rehabilitation in a warm climate (i.e. temperature ± 25°C, dry and sunny) and a cold climate (i.e. temperature ± 0°C, rainy or snowy), static magnetic fields) studies were included in this review. None of the included studies was completely free from any risk of bias and the most prevalent risk of bias was lack of blinding.There is moderate quality evidence that intravenous immunoglobulin has no beneficial effect on activity limitations and there is inconsistency in the evidence for effectiveness on muscle strength and pain. Results of one trial provide very low quality evidence that lamotrigine might be effective in reducing pain and fatigue, resulting in fewer activity limitations. Data from two single trials suggest that muscle strengthening of thumb muscles (very low quality evidence) and static magnetic fields (moderate quality evidence) are beneficial for improving muscle strength and pain, respectively, with unknown effects on activity limitations. Finally, there is evidence varying from very low quality to high quality that modafinil, pyridostigmine, amantadine, prednisone and rehabilitation in a warm or cold climate are not beneficial in PPS.

AUTHORS' CONCLUSIONS

Due to insufficient good quality data and lack of randomised studies it is impossible to draw definite conclusions on the effectiveness of interventions for PPS. Results indicate that IVIG, lamotrigine, muscle strengthening exercises and static magnetic fields may be beneficial but need further investigation.

Psychometric properties of the Fatigue Severity Scale in polio survivors

The objective of this study was to evaluate by means of classical test theory and Rasch analysis the scaling characteristics and psychometric properties of the Fatigue Severity Scale (FSS) in polio survivors. A questionnaire,consisting of five general questions (sex, age, age at time of acute polio, sequelae of polio, and new symptoms), the FSS, and three questions from the Visual Analog Scale questions on fatigue was sent to all 196 polio survivors at the Institute for Rehabilitation in Ljubljana. Responses were assessed in terms of Cronbach's a, item-to-total correlation, factor analysis, and Rasch analysis. Of the128 (65.3%) valid questionnaires returned, those presenting no missing values were used for subsequent analyses (n = 117). The FSS showed good internal consistency: Cronbach's a was greater than 0.95,item-to-total correlation ranged from 0.68 to 0.88. A reduction from seven to three rating categories was necessary to comply with criteria for correct category function. Item difficulty estimates spanned from – 0.91to + 1.09 logits. No item bias was found for sex and age.The internal consistency of FSS was high and its item separation reliability good, indicating a satisfactory replicability of item placement in other samples. In conclusion, Rasch analysis enabled us to confirm the validity of FSS (in its 8-item version, without item 1) as a measure of the severity and impact of physical symptoms of fatigue in polio survivors, so providing a useful starting point for further studies aimed at examining additional psychometric aspects and confirming the appropriateness of the simplification of its rating categories.