Varied clinical patterns, physical activities, muscle enzymes, electromyographic and histologic findings in patients with post-polio syndrome in Taiwan

Describing post-polio syndrome

INTRODUCTION

Patients presenting sequelae of poliomyelitis may present new symptoms, known as post-polio syndrome (PPS).

OBJECTIVE

To identify the clinical and functional profile and epidemiological characteristics of patients presenting PPS.

PATIENTS AND METHODS

We performed a retrospective study of 400 patients with poliomyelitis attended at the Institut Guttmann outpatient clinic, of whom 310 were diagnosed with PPS. We describe patients' epidemiological, clinical, and electromyographic variables and analyse the relationships between age of poliomyelitis onset and severity of the disease, and between sex, age of PPS onset, and the frequency of symptoms.

RESULTS

PPS was more frequent in women (57.7%). The mean age at symptom onset was 52.4 years, and was earlier in women. Age at primary infection >2 years was not related to greater poliomyelitis severity. The frequency of symptoms was: pain in 85% of patients, loss of strength in 40%, fatigue in 65.5%, tiredness in 57.8%, cold intolerance in 20.2%, dysphagia in 11.7%, cognitive complaints in 9%, and depressive symptoms in 31.5%. Fatigue, tiredness, depression, and cognitive complaints were significantly more frequent in women. Fifty-nine percent of patients presented electromyographic findings suggestive of PPS.

CONCLUSIONS

While the symptoms observed in our sample are similar to those reported in the literature, the frequencies observed are not. We believe that patients' clinical profile may be very diverse, giving more weight to such objective parameters as worsening of symptoms or appearance of weakness; analysis of biomarkers may bring us closer to an accurate diagnosis.

Adults with polio are at risk of hip fracture from middle age: A nationwide population-based cohort study

BACKGROUND

Having motor impairment since childhood and being at risk of osteoporosis and falls, adults with polio would be more likely to suffer a hip fracture (HF) and may experience different epidemiological characteristics from the general population.

OBJECTIVE

To estimate the risk and incidence of HF in adults with polio.

DESIGN

Using a national database, we conducted a population-based cohort study. We identified patients with polio using the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) code of 138. For each patient with polio, we randomly selected five age- and sex-matched control subjects. Those subjects aged <40 years were excluded. We analyzed participants aged 40˜64 years (middle-aged) and subjects aged ≥65 years (elderly) separately and recognized subjects who had an HF (ICD-9-CM code, 820) only when they received hospitalization to care for the illness from January 1, 2003 to December 31, 2008.

RESULTS

We identified 403 adults with polio (mean age ± standard deviation, 47.2 ± 8.6 years). Compared to the controls, patients with polio had a higher incidence of HF (all, 4.1 vs. 1.1/1000 person-years, p = 0.002; middle-aged, 2.3 vs. 0.3/1000 person-years, p < 0.001; male, 6.2 vs. 0.9/1000 person-years, p < 0.001); had a younger mean age (±standard deviation) of fracturing a hip (61.0±14.9 vs. 74.4±9.3 years, p = 0.015); had a lower cumulative HF-free probability (±standard error) before the age of 65 years (0.970±0.017 vs. 0.988±0.007, p<0.001) and throughout the study duration (0.415 ± 0.296 vs. 0.682 ± 0.158, p<0.001); and had a higher risk of HF, yielding an adjusted hazard ratio (95% confidence interval) of 3.58 (1.45˜8.79, p = 0.006). Patients with polio aged >48.2 years were likely to experience an HF.

CONCLUSIONS

Adults with polio are at risk of HF. A customized HF prevention program is important for people with polio. The program should be started early in middle-age and should include men.

Post-polio syndrome, report of two cases

El síndrome pospoliomielitis se reconoce como un trastorno neurológico que aparece décadas después de un episodio agudo de poliomielitis y disminuye la capacidad funcional hasta afectar las actividades cotidianas. El evento ocurre en un 20-80% de las personas que fueron afectadas por el virus de la poliomielitis, es más frecuente en las mujeres y existe una relación directa entre el riesgo de padecer este síndrome y el grado de severidad de las secuelas de la polio. El objetivo de este artículo es la presentación de dos casos clínicos de pacientes que presentaron este síndrome después de cerca de cuarenta años de haber presentado un episodio de poliomielitis.  Se cuestiona el concepto de la poliomielitis como una enfermedad estática; además, en los casos presentados esta patología constituye un proceso de difícil diagnóstico y manejo. El impacto psicológico y funcional en los pacientes se asume como un reto para el profesional de salud, puesto que se deben identificar las necesidades clínicas y reducir las barreras asistenciales existentes en la actualidad.

Post-polio syndrome. Cases report and review of literature

It is estimated that around 15 million people survived polio infection worldwide since early twentieth century. In 1950 effective vaccination was used for first time. Since that time number of affected people decreased. The last epidemic of Haine-Medine disease in Poland was in 1950s. Another rare cases of infections were observed till 1970s. About at least 15 years after polio virus infection, slowly progressive muscle limbs paresis with muscle atrophy, joints pain, paresthesia were observed in polio survivors. That constellation of symptoms was called post-polio syndrome (PPS). PPS frequency among people after paralytic and nonparalytic polio infectious is ranged from 30% to 80%. Fatigue that leads to physical and mental activity deterioration is another important symptom that is observed in 90% of patients with PPS. Etiology of disease remains elusive. Probably it is an effect of spine frontal horns motoneurons damage during acute virus polio infection that leads to overloading and degeneration of remaining ones. The most important risk factors of PPS are female sex and respiratory symptoms during acute polio infection. Electromyography is an important part of PPS diagnostic process. Electrophysiological abnormalities are seen in clinically affected and unaffected muscles. The most frequent are fasciculations and fibrillations during rest activity, extension of motor unit area, time duration and amplitude. In this study we described three cases of people who developed PPS years after Haine-Medine disease and correlation between their EMG results and clinical status. We also analyzed electromyography results both after one month since first PPS signs occurred as well as after few years. Presentation of dynamic changes in EMG was the most important aim of that study.

Post-poliomyelitis syndrome: case report

The post-polio syndrome (PPS) is an entity characterized for an episode of muscular weakness and/or abnormal muscular fatigue in individuals that had presented acute polio years before. We report the case of PPS in a patient, 40 years, that thirty-five years after had had paralytic poliomyelitis, developed new symptoms of fatigue, muscular atrophy, dyspnea, difficulties in deambulation and muscular and joint pain. The electromyographic findings revealed injuried neurons of the anterior horn of the marrow and reinnervation after muscular tests.

Post-polio syndrome: clinical manifestations and cerebrospinal fluid markers

Post-polio syndrome (PPS) refers to a constellation of new neurological, musculoskeletal and general symptoms occurring in survivors of poliomyelitis decades after acute paralytic and nonparalytic disease. The common manifestations of PPS include generalized, central and peripheral fatigue, muscle weakness and musculoskeletal pain. The pathogenesis of PPS remains obscure. Three prevailing hypotheses have been advanced: stress-induced degeneration of surviving neurons, persistent poliovirus replication or virus reactivation and immune-mediated damage. The diagnosis of PPS is based on medical history and clinical examination, since no specific diagnostic tests are available. In the light of recent studies demonstrating a partial beneficial effect of intravenous immunoglobulin, this article will focus on cerebrospinal fluid biomarkers reflecting disease activity and pathogenic processes in PPS.

Physical therapist management following rotator cuff repair for a patient with postpolio syndrome

BACKGROUND AND PURPOSE

Postpoliomyelitis sequelae, such as gait instability and progressive weakness, predispose people with postpolio syndrome to secondary disabilities. With aging, people who depend on their upper extremities to accommodate lower-extremity deficits may anticipate overuse injuries. The purpose of this case report is to describe the use of mobilization and exercise in postoperative rehabilitation of rotator cuff surgery on a patient with postpolio syndrome.

CASE DESCRIPTION

A 48-year-old woman with postpolio syndrome had rotator cuff surgical repair followed by physical therapy intervention. Maitland mobilization and mild functional exercises were chosen to avoid triggering fatigue.

OUTCOMES

Measurements taken preoperatively, before and after physical therapy intervention, and 2 years after intervention showed return to independent status with excellent retention.

DISCUSSION

No fatigue or overuse weakness was encountered. This is the first case report to document physical therapy following rotator cuff repair in a patient with postpolio syndrome.

EFNS guideline on diagnosis and management of post-polio syndrome. Report of an EFNS task force

Post-polio syndrome (PPS) is characterized by new or increased muscular weakness, atrophy, muscle pain and fatigue several years after acute polio. The aim of the article is to prepare diagnostic criteria for PPS, and to evaluate the existing evidence for therapeutic interventions. The Medline, EMBASE and ISI databases were searched. Consensus in the group was reached after discussion by e-mail. We recommend Halstead's definition of PPS from 1991 as diagnostic criteria. Supervised, aerobic muscular training, both isokinetic and isometric, is a safe and effective way to prevent further decline for patients with moderate weakness (Level B). Muscular training can also improve muscular fatigue, muscle weakness and pain. Training in a warm climate and non-swimming water exercises are particularly useful (Level B). Respiratory muscle training can improve pulmonary function. Recognition of respiratory impairment and early introduction of non-invasive ventilatory aids prevent or delay further respiratory decline and the need for invasive respiratory aid (Level C). Group training, regular follow-up and patient education are useful for the patients' mental status and well-being. Weight loss, adjustment and introduction of properly fitted assistive devices should be considered (good practice points). A small number of controlled studies of potential-specific treatments for PPS have been completed, but no definitive therapeutic effect has been reported for the agents evaluated (pyridostigmine, corticosteroids, amantadine). Future randomized trials should particularly address the treatment of pain, which is commonly reported by PPS patients. There is also a need for studies evaluating the long-term effects of muscular training.

Anaerobic and aerobic enzyme activities in human skeletal muscle from children and adults

Literature has shown that children have lower anaerobic capacity and oxidize more lipids during aerobic activity compared with adults. The purpose of the present study was to examine the effects of age on the activity of marker enzymes for anaerobic and aerobic metabolism in human skeletal muscle from relatively sedentary children and adults. The m. obliquus internus abdominis was analyzed for anaerobic [creatine kinase, adenylate kinase, and lactate dehydrogenase (LDH)] and aerobic (carnitine palmitoyltransferase and 2-oxoglutarate dehydrogenase) enzyme activities in 32 male individuals. The subjects were divided into two groups: children (3-11 y; n=20) and adults (29-54 y; n=12). LDH activity was higher in adults (118.2 +/- 20.1) compared with children (27.8 +/- 10.1) micromol.min(-1).g(-1) wet weight (p <0.0002). Creatine kinase activity was 28% (p <0.0003) lower in children than in adults, and adenylate kinase activity was 20% (p <0.006) lower in children than in adults. In addition, we found higher 2-oxoglutarate dehydrogenase activity in adults compared with children (p <0.04), with no effect of age on carnitine palmitoyltransferase activity (NS). When samples were expressed relative to protein content, only LDH activity remained significantly lower in children compared with adults (p <0.0001). In conclusion, the lower LDH activity observed in children compared with adults may partially explain decreased anaerobic and lactate generation capacity of the children studied. However, the mechanisms for the relatively deficient anaerobic enzyme activities of children are not clear.

Postpolio syndrome: a challenge to the health-care system

The practical eradication of poliomyelitis in industrialized countries marks one of the most important achievements of world health policy. Yet, disability induced by polio not only continues to exist among survivors with paralytic sequelae, but may also be further accentuated in a considerable number of affected subjects by the development of postpolio syndrome (PPS). PPS aggravates the motor sequelae already present in such subjects and reduces their functional capacity to the point where it affects their activities of daily living and worsens their quality of life. Inasmuch as development of PPS questions the concept of poliomyelitis as a static disease it poses a challenge not only to health professionals but also to policy-makers tasked with providing the necessary health-care measures and appropriate resources. This study sought to review research on this syndrome and to draw up some recommendations that might prove useful to the health authorities for decision-making purposes.

Lifestyle and late effects after poliomyelitis. A risk factor study of two populations

BACKGROUND

Patients with polio often experience new symptoms (muscle weakness, pain, fatigue and respiratory problems) many years after the acute disease. This study examined possible interactions between lifestyle factors (overweight, physical inactivity, smoking) and late polio with new symptoms.

METHODS

A total of 148 patients hospitalized for acute polio in 1950-1954 at Haukeland University Hospital, Norway and 128 patients, hospitalized for acute polio in 1958 at Tartu University Hospital, Estonia responded to a mailed questionnaire regarding lifestyle and late polio with new symptoms. Multiple regression analysis, two samples t-test and chi-square analysis were undertaken.

RESULTS

Mean body mass index (BMI) and percentage of smokers did not differ in the two cohorts, while polio patients were physically less active in Estonia. The physically active patients in both cohorts had significantly lower odds for experiencing polio-related late muscle pain (OR = 0.21; 95% CI = 0.08-0.55) and fatigue (OR = 0.32; 95% CI = 0.14-0.75). With increasing age the patients had significantly higher odds for experiencing new muscle weakness (OR = 1.03; 95% CI = 1.00-1.07), fatigue (OR = 1.04;95% CI = 1.01-1.07) and breath shortness (OR = 1.04; 95% CI = 1.00-1.07).

CONCLUSION

Physically inactive patients are at a higher risk for late polio-related symptoms. An active lifestyle should be recommended for patients with polio sequels.

Randomized controlled trial of strength training in post-polio patients

Many post-polio patients develop new muscle weakness decades after the initial illness. However, its mechanism and treatment are controversial. The purpose of this study was to test the hypotheses that: (1) after strength training, post-polio patients show strength improvement comparable to that seen in the healthy elderly; (2) such training does not have a deleterious effect on motor unit (MU) survival; and (3) part of the strength improvement is due to an increase in voluntary motor drive. After baseline measures including maximum voluntary contraction force, voluntary activation index, motor unit number estimate, and the tetanic tension of the thumb muscles had been determined, 10 post-polio patients with hand involvement were randomized to either the training or control group. The progressive resistance training program consisted of three sets of eight isometric contractions, three times weekly for 12 weeks. Seven healthy elderly were also randomized and trained in a similar manner. Changes in the baseline parameters were monitored once every 4 weeks throughout the training period. The trained post-polio patients showed a significant improvement in their strength (P < 0.05). The magnitude of gain was greater than that seen in the healthy elderly (mean +/- SE, 41 +/- 16% vs. 29 +/- 8%). The training did not adversely affect MU survival and the improvement was largely attributable to an increase in voluntary motor drive. We therefore conclude that moderate intensity strength training is safe and effective in post-polio patients.