Dynamic water exercise in individuals with late poliomyelitis

Quantitative modelling of Ostracod bioassay: assigning toxicity index to potentially chemical contaminated swimming pools

One of the primary objectives of any public health programme is to design a protocol that will curtail a population from being predisposed to toxic substances in the environment. Biomarkers help in actualising such an objective by their potential to detect the presence of toxic substances in environmental media such as soil, water and air. The Ostracod Heterocypris incongruens, an already established biomarker for quality evaluation of freshwater, does not quantify toxicity. This work was aimed at modelling Ostracod bioassay as a quantitative whole-water toxicity assay (QWTA) for the determination of potentially chemical contaminated swimming pools. In this modelling approach, a pool water sample was deliberately contaminated with a mixture of Fenton reagent (FR) and Bonny light (BL) crude oil. The mechanism of toxic injury of this mixture is via oxidative stress-mediated superoxide ion and other free radicals. The mortalities and growth factors of the exposed freshly hatched Ostracods to the serial dilutions of the contaminated swimming pool water sample for 6 days were mathematically modelled to toxicity indices (Ti), which were used to construct the toxicity reference curve (TRC). A graph of the "toxic concentrations" of the serially diluted contaminated pool water sample against Ostracod mortality was plotted. The TRC and the linear graph constitute the "Ostracod-linked mathematical model". Against the reference mortality ≤ 20% of the Ostracods, the toxicity index based on the model prediction is ≤ 32.5, and this signifies "no observed toxic effect" for toxicity values below 32.5 units. Using this model, toxicity indices were calculated for 5 randomly selected swimming pools in the study area. The results showed that the outdoor pool SP 5 has a toxic index of 49.0, while outdoor pools SP 2 and SP 3 each has a toxic index of 42.5. The indoor swimming pool (SP 4) and Standard water (control) have zero toxicity, thus suggesting that that the outdoor pools SP 2, SP 3 and SP 5 were possibly contaminated by chemicals from extraneous sources while contamination of SP 1 was very much negligible, hence the "no observed toxic effect".

Aquatic Therapy for Persons with Neuromuscular Diseases - A Scoping Review

Background:

Aquatic exercise is among the most common physical activity modalities performed by people with disabilities.

Objective:

The present paper reviews currently-available research on aquatic therapy (AT) for persons with neuromuscular diseases (NMD).

Methods:

A scoping review of the existing literature was conducted on PubMed, Embase, Medline, Scopus, Web of Science, SPORTdiscus, CINAHL and Lilacs from the earliest date available until October 2020. It follows the methodological framework for conducting a scoping review proposed by the Joanna Briggs Institute.

Results:

A total of 28 articles were analyzed and the study parameters grouped by the topography of NMD; most of the studies (n = 16) addressed myopathies. A considerable increase in the number of studies was found over time, and heterogeneity was identified across and within AT interventions for persons with NMD; hence, to allow more effective interpretation of study results, there is a need to standardize the fundamental parameters and procedures for AT.

Conclusions:

This scoping review provides a comprehensive outline of available literature; the findings could serve as a starting point for clinical studies on the effects of AT on persons with NMD, and encourage a more coherent approach to their design.

Aquatic Exercise and Land Exercise Treatments after Total Knee Replacement Arthroplasty in Elderly Women: A Comparative Study

Background and Objectives: Early intensive exercise after total knee replacement arthroplasty (TKRA) has become increasingly popular due to its ability to enhance knee physical function and reduce pain. When implemented exclusively, aquatic exercise (AE) appears to be more advantageous than land exercise (LE), particularly in the early phase after TKRA. Our study aimed to compare the clinical efficacy of AE and LE with respect to their effects on pain and physical function after TKRA. Materials and Methods: Between February 2008 and January 2020, 100 female patients who underwent TKRA were enrolled in this retrospective study. We measured the range of motion (ROM) of the knee, the isokinetic strength of the knee joint (function), and pain both initially and one month after TKRA. Two weeks after TKRA, the participants were enrolled in either the AE or the LE program for a total of two weeks. Two 30 min sessions of intensive ROM and knee strengthening exercises and balance training were provided to the AE and LE groups for 10 days. The home exercise group (HE) only received information on ROM and strengthening exercises. There were 33, 21, and 46 patients allocated to the AE, LE, and HE groups, respectively. Results: The ROM of the side on which surgery was performed improved significantly in all groups, as did the pain scores. In the AE group, the knee flexor strength showed a tendency toward improvement. Contrastingly, there was no significant improvement in the knee extensor strength in the AE group. Conclusions: Overall, the AE and LE groups showed superior outcomes compared with HE. In addition, the AE group demonstrated some improvement in knee muscle strength even with a short hospital stay. Further study with long-term follow-up should be performed to better define the outcomes.

Individualized Aerobic Exercise in Neuromuscular Diseases: A Pilot Study on the Feasibility and Preliminary Effectiveness to Improve Physical Fitness

OBJECTIVE

Clear guidelines to prescribe aerobic exercise in neuromuscular diseases (NMD) are lacking, which hampers effective application in neuromuscular rehabilitation. This pilot study evaluated the feasibility and preliminary effectiveness of an individualized aerobic exercise program according to a recently developed training guide (B-FIT) to improve physical fitness in individuals with NMD.

METHODS

Thirty-one individuals who were ambulatory and had 15 different slowly progressive NMD participated in a 4-month, polarized, home-based, aerobic exercise program. The program included 2 low-intensity sessions and 1 high-intensity session per week. Feasibility outcomes were the following: completion rate, proportion of followed sessions, adverse events, and participant and therapist satisfaction based on a self-designed questionnaire. Submaximal incremental exercise tests were used to assess the effects on physical fitness.

RESULTS

Twenty-six participants (84%) completed the B-FIT program, and the proportion of followed sessions was >75%. Three adverse events were reported and resolved. Regarding satisfaction, participants (based on n = 9) reported feeling fitter, but training was considered insufficiently challenging. Physical therapists (n = 5) reported that B-FIT provides a clear, well-grounded guidance. They perceived the time investment for initiating the program and the carry-over to primary care as the main barriers. The mean (SD) submaximal heart rate (based on n = 20) reduced significantly by -6.5 beats per minute (95% CI = -11.8 to -1.2), from 121.7 (16.5) at baseline to 115.2 (14.3) after intervention. Submaximal ratings of perceived exertion, anaerobic threshold, and peak workload also improved significantly (P < .05).

CONCLUSION

The outcomes of this pilot study suggest that individualized aerobic exercise according to B-FIT is feasible and has potential to improve physical fitness in a wide variety of slowly progressive NMD. However, some barriers must be addressed before investigating the efficacy in a randomized controlled trial.

IMPACT

The outcomes of this study demonstrate the feasibility of individualized aerobic exercise according to the B-FIT training guide and the potential to improve physical fitness in NMD. Physical therapists indicated that the use of B-FIT provides a clear, well-grounded guidance. The training guide can support health care professionals in the application of aerobic exercise in adult neuromuscular rehabilitation.

LAY SUMMARY

Individualized exercise according to the B-FIT training guide is feasible in a wide variety of slowly progressive NMD and might help improve physical fitness.

Post-polio Syndrome: More Than Just a Lower Motor Neuron Disease

Post-polio syndrome (PPS) is a neurological condition that affects polio survivors decades after their initial infection. Despite its high prevalence, the etiology of PPS remains elusive, mechanisms of progression are poorly understood, and the condition is notoriously under-researched. While motor dysfunction is a hallmark feature of the condition, generalized fatigue, sleep disturbance, decreased endurance, neuropsychological deficits, sensory symptoms, and chronic pain are also often reported and have considerable quality of life implications in PPS. The non-motor aspects of PPS are particularly challenging to evaluate, quantify, and treat. Generalized fatigue is one of the most distressing symptoms of PPS and is likely to be multifactorial due to weight-gain, respiratory compromise, poor sleep, and polypharmacy. No validated diagnostic, monitoring, or prognostic markers have been developed in PPS to date and the mainstay of therapy centers on symptomatic relief and individualized rehabilitation strategies such as energy conservation and muscle strengthening exercise regimes. Despite a number of large clinical trials in PPS, no effective disease-modifying pharmacological treatments are currently available.

Post-polio syndrome and the late effects of poliomyelitis: Part 2. treatment, management, and prognosis

Post-polio syndrome (PPS) is characterized by new muscle weakness and/or muscle fatigability that occurs many years after the initial poliomyelitis illness. An individualized approach to rehabilitation management is critical. Interventions may include rehabilitation management strategies, adaptive equipment, orthotic equipment, gait/mobility aids, and a variety of therapeutic exercises. The progression of muscle weakness in PPS is typically slow and gradual; however, there is also variability in both the natural history of weakness and functional prognosis. Further research is required to determine the effectiveness of selected medical treatment. Muscle Nerve 58:760-769, 2018.

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

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.

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.

The effects of aquatic therapy on mobility of individuals with neurological diseases: a systematic review

Objective:

To summarize evidence on the effects of aquatic therapy on mobility in individuals with neurological diseases.

Data sources:

MEDLINE, EMBASE, PsycInfo, CENTRAL, CINAHL, SPORTDiscus, PEDro, PsycBITE and OT Seeker were searched from inception to 15 September 2014. Hand-searching of reference lists was performed in the selected studies.

Review methods:

The search included randomized controlled trials and quasi-experimental studies that investigated the use of aquatic therapy and its effect on mobility of adults with neurological diseases. One reviewer screened titles and abstracts of retrieved studies from the search strategy. Two reviewers independently examined the full texts and conducted the study selection, data extraction and quality assessment. A narrative synthesis of data was applied to summarize information from included studies. The Downs and Black Scale was used to assess methodological quality.

Results:

A total of 116 articles were obtained for full text eligibility. Twenty studies met the specified inclusion criteria: four Randomized Controlled Trials (RCTs), four non-randomized studies and 12 before-and-after tests. Two RCTs (30 patients with stroke in the aquatic therapy groups), three non-randomized studies and three before-and-after studies showed “fair” evidence that aquatic therapy increases dynamic balance in participants with some neurological disorders. One RCT (seven patients with stroke in the aquatic therapy group) and two before-and-after tests (20 patients with multiple sclerosis) demonstrated “fair” evidence on improvement of gait speed after aquatic therapy.

Conclusion:

Our synthesis showed “fair” evidence supporting the use of aquatic therapy to improve dynamic balance and gait speed in adults with certain neurological conditions.

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.

Exercise in neuromuscular diseases

This article reviews the current knowledge regarding the benefits and contraindications of exercise on individuals with neuromuscular diseases (NMDs). Specific exercise prescriptions for individuals with NMDs do not exist because the evidence base is limited. Understanding the effect of exercise on individuals with NMDs requires the implementation of a series of multicenter, randomized controlled trials that are sufficiently powered and use reliable and valid outcome measures to assess the effect of exercise interventions-a major effort for each NMD. In addition to traditional measures of exercise efficacy, outcome variables should include measures of functional status and health-related quality of life.

Curative and health enhancement effects of aquatic exercise: evidence based on interventional studies

BACKGROUND

The purpose of this study was to report on the health benefits and curative effects of aquatic exercise.

METHODS

We adopted the results of high-grade study designs (ie, randomized controlled trials and nonrandomized controlled trials), for which there were many studies on aquatic exercise. Aquatic exercise, in this study, means walking in all directions, stretching, and various exercises and conditioning performed with the feet grounded on the floor of a swimming pool. We excluded swimming. We decided to treat aquatic exercise, underwater exercise, hydrotherapy, and pool exercise as all having the same meaning.

RESULTS

Aquatic exercise had significant effects on pain relief and related outcome measurements for locomotor diseases.

CONCLUSION

Patients may become more active, and improve their quality of life, as a result of aquatic exercise.

A systematic review of nonrandomized controlled trials on the curative effects of aquatic exercise

Background:

The objectives of this review were to integrate the evidence of curative effects through aquatic exercise and assess the quality of studies based on a review of nonrandomized controlled trials (nRCTs).

Methods:

Study design was a systematic review of nonrandomized controlled trials. Trials were eligible if they were nonrandomized clinical trials. Studies included one treatment group in which aquatic exercise was applied. We searched the following databases from 2000 up to July 20, 2009: MEDLINE via PubMed, CINAHL, and Ichushi-Web.

Results:

Twenty-one trials met all inclusion criteria. Languages included were English (N = 9), Japanese (N = 11), and Korean (N = 1). Target diseases were knee and/or hip osteoarthritis, poliomyelitis, chronic kidney disease, discomforts of pregnancy, cardiovascular diseases, and rotator cuff tears. Many studies on nonspecific disease (healthy participants) were included. All studies reported significant effectiveness in at least one or more outcomes. However results of evaluations with the TREND and CLEAR-NPT checklists generally showed a remarkable lack of description in the studies. Furthermore, there was the problem of heterogeneity, and we were therefore not able to perform a meta-analysis.

Conclusion:

Because there was insufficient evidence on aquatic exercise due to poor methodological and reporting quality and heterogeneity of nRCTs, we were unable to offer any conclusions about the effects of this intervention. However, we were able to identify problems with current nRCTs of aquatic exercise, and propose a strategy of strengthening study quality, stressing the importance of study feasibility as a future research agenda objective.

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.

Update on current and emerging treatment options for post-polio syndrome

Post-polio syndrome (PPS) refers to the clinical deterioration experienced by many polio survivors several decades after their acute illness. The symptoms are new muscle weakness, decreased muscle endurance, fatigue, muscle pain, joint pain, cold intolerance, and this typical clinical entity is reported from different parts of the world. The pathophysiology behind PPS is not fully understood, but a combination of distal degeneration of enlarged motor units caused by increased metabolic demands and the normal aging process, in addition to inflammatory mechanisms, are thought to be involved. There is no diagnostic test for PPS, and the diagnosis is based on a proper clinical workup where all other possible explanations for the new symptoms are ruled out. The basic principle of management of PPS lies in physical activity, individually tailored training programs, and lifestyle modification. Muscle weakness and muscle pain may be helped with specific training programs, in which training in warm water seems to be particularly helpful. Properly fitted orthoses can improve the biomechanical movement pattern and be energy-saving. Fatigue can be relieved with lifestyle changes, assistive devices, and training programs. Respiratory insufficiency can be controlled with noninvasive respiratory aids including biphasic positive pressure ventilators. Pharmacologic agents like prednisone, amantadine, pyridostigmine, and coenzyme Q10 are of no benefit in PPS. Intravenous immunoglobulin (IVIG) has been tried in three studies, all having positive results. IVIG could probably be a therapeutic alternative, but the potential benefit is modest, and some important questions are still unanswered, in particular to which patients this treatment is useful, the dose, and the therapeutic interval.

Rehabilitation management of neuromuscular disease: the role of exercise training

This paper summarizes the current state of knowledge regarding exercise and neuromuscular diseases/disorders (NMDs) and reviews salient studies in the literature. Unfortunately, there is inadequate evidence in much of the NMDs to make specific recommendations regarding exercise prescriptions. This review focuses on the role of exercise in a few of the specific NMDs where most research has taken place and recommends future research directions.

Effective intervention strategies for management of impaired posture and fatigue with post-polio syndrome: A case report

This case report describes effective intervention strategies that included gait training with the use of an acceptable, assistive device for the management of impaired posture and fatigue associated with post-polio syndrome. Review of videotaped gait-training sessions enhanced patient compliance with the assistive device, a single forearm crutch. The 49-year-old female acquired childhood polio with resulting leg length discrepancy, lower extremity weakness, and complaints of fatigue. She walked with a right ankle foot orthosis and increased right lateral trunk flexion during right stance. Interventions consisted of patient education regarding the diagnosis and management of post-polio syndrome, health promotion, and energy conservation strategies that included gait training with a single forearm crutch. An outcome measure not previously documented in the post-polio literature was used to measure the patient's perceived fatigue. Six-month and 18-month reexaminations found that the patient was compliant with the assistive device, reported a 30% reduction in fatigue, and walked with a more upright posture for longer distances in a shorter period of time. Patient education, health promotion, and energy conservation strategies that included walking with a properly fitting assistive device reduced perceived fatigue and improved posture and function in an individual with post-polio syndrome.

Benign paroxysmal positional vertigo recurrence and persistence

Aim

Study design

Materials and Methods

Results

Short-term effects of aerobic exercise on functional capacity, fatigue, and quality of life in patients with post-polio syndrome

OBJECTIVE

To investigate and compare the impact of hospital and home exercise programmes on aerobic capacity, fatigue, and quality of life in patients with post-polio syndrome.

DESIGN

A prospective, randomized controlled trial.

SETTING

Department of Physical Medicine and Rehabilitation, University Hospital.

SUBJECTS

Thirty-two patients were divided into two groups for either hospital- or home-based aerobic exercise programme.

MAIN OUTCOME MEASURES

Patients were assessed before and after the rehabilitation programme, with respect to functional capacity (pVo2), fatigue (Fatigue Severity Scale, Fatigue Impact Scale) and quality of life (Nottingham Heath Profile).

RESULTS

After the exercise programme, improvement was observed in the hospital exercise group compared to a pre-exercise period in all Nottingham Heath Profile scores (except sleep scores), pVo2, Fatigue Severity Scale and Fatigue Impact Scale (cognitive, physical, psychosocial, total) (P<0.05). In contrast, in the home exercise group a decrease was observed in pVo2 scores after the rehabilitation programme, compared to a pre-rehabilitation period (P<0.05). In addition, a significant improvement was observed in the home exercise group after the rehabilitation programme in all parameters excluding Fatigue Impact Scale-physical, Fatigue Impact Scale-psychosocial, and Nottingham Heath Profile-sleep (P<0.05). When the two exercise groups were compared, improvement was observed in the hospital exercise group compared to the home exercise group in pVo2 and Fatigue Severity Scale-total, Fatigue Impact Scale-physical, Fatigue Impact Scale-psychosocial, Fatigue Impact Scale-total, and Nottingham Heath Profile-energy scores (P<0.05).

CONCLUSION

Fatigue and quality of life were both improved in the home and hospital exercise groups. An increase was also found in the functional capacity in the hospital exercise group. A regular exercise programme is beneficial to patients with post-polio syndrome.

The effect of aquatic therapy on postural balance and muscle strength in stroke survivors — a randomized controlled pilot trial

Objective: To evaluate the effect of an aquatic therapy programme designed to increase balance in stroke survivors.

Design: A randomized, controlled pilot trial.

Setting: Rehabilitation department of a university hospital.

Subjects: Ambulatory chronic stroke patients (n = 25):13 in an aquatic therapy group and 12 in a conventional therapy group.

Interventions: The aquatic therapy group participated in a programme consisting of Ai Chi and Halliwick methods, which focused on balance and weight-bearing exercises. The conventional therapy group performed gym exercises. In both groups, the interventions occurred for 1 hour, three times per week, for eight weeks.

Main measures: The primary outcome measures were Berg Balance Scale score and weight-bearing ability, as measured by vertical ground reaction force during four standing tasks (rising from a chair and weight-shifting forward, backward and laterally). Secondary measures were muscle strength and gait.

Results: Compared with the conventional therapy group, the aquatic therapy group attained significant improvements in Berg Balance Scale scores, forward and backward weight-bearing abilities of the affected limbs, and knee flexor strength (P<0.05), with effect sizes of 1.03, 1.14, 0.72 and 1.13 standard deviation units and powers of 75, 81, 70 and 26%, respectively. There were no significant changes in the other measures between the two groups.

Conclusions: Postural balance and knee flexor strength were improved after aquatic therapy based on the Halliwick and Ai Chi methods in stroke survivors. Because of limited power and a small population base, further studies with larger sample sizes are required.

Assessing walking speed in clinical research: a systematic review

OBJECTIVE

To provide a systematic review and describe how assessments of walking speed are reported in the health care literature.

METHODS

MEDLINE electronic database and bibliographies of select articles were searched for terms describing walking speed and distances walked. The search was limited to English language journals from 1996 to 2006. The initial title search yielded 793 articles. A review of the abstracts reduced the number to 154 articles. Of these, 108 provided sufficient information for inclusion in the current review.

RESULTS

Of the 108 studies included in the review 61 were descriptive, 39 intervention and 8 randomized controlled trials. Neurological (n=55) and geriatric (n=27) were the two most frequent participant groups in the studies reviewed. Instruction to walk at a usual or normal speed was reported in 55 of the studies, while 31 studies did not describe speed instructions. A static (standing) start was slightly more common than a dynamic (rolling) start (30 vs 26 studies); however, half of the studies did not describe the starting protocol. Walking 10, 6 and 4 m was the most common distances used, and reported in 37, 20 and 11 studies respectively. Only four studies included information on whether verbal encouragement was given during the walking task.

CONCLUSIONS

Tests of walking speed have been used in a wide range of populations. However, methodologies and descriptions of walking tests vary widely from study to study, which makes comparison difficult. There is a need to find consensus for a standardized walking test methodology.

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.

The Relation Between Walking Capacity and Clinical Correlates in Survivors of Chronic Spinal Poliomyelitis

OBJECTIVES

To examine (1) common clinical measures that may influence walking performance in the six-minute walk test (6MWT) in people with chronic poliomyelitis and (2) the test-retest reliability of the 6MWT distance, lower-extremity muscle strength, balance, and balance confidence on separate trials.

DESIGN

A prospective quasi-experimental study.

SETTING

University-based postpolio clinic.

PARTICIPANTS

Nineteen survivors of poliomyelitis (mean age, 62.2+/-1.9y; time since polio onset, 54.4+/-8.79y).

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

6MWT distance, rate-pressure product (RPP), Physiological Cost Index (PCI), ratings of perceived exertion (RPE), pain, fatigue, strength, standing balance, balance confidence, limb-length discrepancy, and lung function.

RESULTS

The 6MWT distance correlated with PCI, pretest pain, lower-extremity muscle strength, balance, balance confidence, corrected leg-length discrepancy, and lung function but not with RPP, RPE, posttest pain, or pretest and posttest fatigue. The PCI correlated with balance confidence and lung function. About 68% of the variance in 6MWT distance was accounted for by balance and pretest pain. The P value was set at .05.

CONCLUSIONS

With stringent standardization of the 6MWT applied to survivors of poliomyelitis (a neuromuscular condition with a musculoskeletal component), reproducibility was high; hence, test validity and interpretation were enhanced. The 6MWT distance was useful in elucidating the relation between impairment and a functional activity-namely, walking-in survivors of poliomyelitis.

Postural control in persons with late effects of polio

BACKGROUND

Persons who have suffered from acute poliomyelitis may decades later experience reduction of balance and gait capacity due to muscle weakness, fatigue and/or pain. This may affect the activity level in daily life of these persons.

AIMS OF THE STUDY

The aim of this study was to describe observer assessed and subjectively perceived postural control in persons with late effects of polio and to evaluate the correlation between postural control and gait velocity for this population.

METHOD

50 persons (mean age 59.8 yrs) with diagnosed polio disease and without other causes of mobility disorders were included. Balance was tested with the Timed Up and Go test (TUG), the Functional Reach test (FR) and the Falls Efficacy Scale (FES) (Swedish Version). Gait velocity over 30 m was measured for convenient and maximal velocity.

RESULTS

The subjects had reduced balance (TUG mean 9.0 sec, FR mean 23.5 cm) and perceived balance problems in ADL items (FES(S) median 119.5, normal value 130). They also showed reduced gait velocity compared to healthy persons of the same age (mean 1.01 m/s compared to 1.30 m/s, convenient speed). Correlations were demonstrated between the reduced balance and decreased convenient and maximal gait velocity (TUG/gait velocity: r = -0.7 (convenient), r = -0.8 (maximal), p <or= 0.01).

CONCLUSIONS

The knowledge of reduced balance and gait velocity in persons with late effects of polio may have an impact on how to provide service to this group to ensure safety in activities in daily life, including gait.

Secondary conditions and life satisfaction among polio survivors

Persons living with the effects of polio are often at increased risk for the development of secondary conditions and disabilities that can lead to further decline in health status, independence, functional status, life satisfaction, and overall quality of life. The purpose of this study was to explore the frequency of selected secondary conditions, factors associated with these conditions, and the relationship between secondary conditions and quality of life among polio survivors. Data from a large convenience sample (N = 2,153) indicate that secondary conditions are prevalent and associated with decreased life satisfaction. Prompt identification and treatment of secondary conditions before they progress to greater impairment and/or disability and attention to an overall healthful lifestyle is important to preserve function and maintain quality of life of polio survivors.

Walking in postpoliomyelitis syndrome: the relationships between time-scored tests, walking in daily life and perceived mobility problems

OBJECTIVE

To compare walking test results with walking in daily life, and to investigate the relationships between walking tests, walking activity in daily life, and perceived mobility problems in patients with post-poliomyelitis syndrome.

SUBJECTS

Twenty-four ambulant patients with post-poliomyelitis syndrome.

METHODS

Walking tests were performed at self-preferred and maximal speed. Walking activity was measured with an ambulatory activity monitor. Heart rate, step cadence and walking speed in the test and in daily life were compared. Walking speed in daily life was represented by the intensity of walking. Perceived mobility problems were assessed with the Nottingham Health Profile.

RESULTS

Heart rate during walking was lower in the test at self-preferred speed than in daily life (mean difference: 11.3+/-10.4; p=0.001). Self-preferred walking speed in the test and in daily life correlated significantly (r=0.55; p=0.04). In a sub-group with a test performance below the median value, test performance correlated significantly with walking activity. No significant correlation was found between perceived mobility problems and walking activity.

CONCLUSION

Walking in daily life may be more demanding than walking under standardized conditions. Patients with post-poliomyelitis syndrome with the lowest test performance walked less in daily life. Patients do not necessarily match their activity pattern to their perceived mobility problems.

Aging in polio

For a disease that was "conquered" some 40 years ago with the onset of effective vaccination, the issues of long-term survivors of paralytic polio as they age continue to present challenges to rehabilitation specialists. Aging with polio is a definition of PPS. There are over a million patients with PPS in the United States. Management has to include the appropriate use of exercises, appropriate bracing and support, and, in the case of bulbar and respiratory symptoms, the appropriate use of speech therapy services and ventilatory support. There are no prospective randomized trials studying the treatment of weakness and fatigue in PPS. Pharmacologic interventions are limited at this time but include anticholinergics for muscle weakness and dopaminergic agents or amantadine to control central fatigue. The pathophysiology of aging with polio is consistent with neuronal loss and denervation lying at the heart of the developing disorder, whereas the central nervous system components of the fatigue syndrome may be related to central changes with neuronal loss in the basal ganglia and reticular-activating system. Many of the survivors of the polio epidemics are in their later retirement years, and their needs will increase as they have other disabilities due to natural aging. Sensitivity to some of the special issues in PPS may help to avoid complications. Polio is an active infection in the third world. Although great strides have been made, the disease is endemic in eight nations and is threatening to spread. The lessons learned in treating PPS now will be useful in years to come as these individuals age and manifest PPS in the future.

Practical considerations in the assessment and treatment of pain in adults with physical disabilities

Adults aging with physical disabilities experience a variety of pain disorders that affect their functionality and QOL. It is important that clinicians caring for this population be knowledgeable about this common symptom and be able to perform a thorough history and physical examination. In addition, it is imperative to have a good working knowledge of the strengths and limitations of the treatments available.

An explanatory model of health promotion and quality of life for persons with post-polio syndrome

Although previous studies have examined selected factors influencing health promoting behaviors or quality of life, the complex interplay of these variables in persons with different chronic disabling conditions has not been investigated. This study tested an explanatory model of variables influencing health promotion and quality of life originally developed with a sample of persons with multiple sclerosis in a new sample of persons living with post-polio syndrome (PPS) in the USA. The sample of 1603 persons with PPS (1123 females, 478 males and 2 unknown) completed a battery of instruments including measures of severity of polio-related impairment, barriers to health promoting behaviors, resources, self-efficacy, acceptance, health promoting behaviors and perceived quality of life. A model originally developed in a sample of 786 persons with multiple sclerosis was assessed and modified using the weighted least squares procedure (WLS) which is implemented by LISREL8. The structural equation analyses resulted in a proper solution that exhibited adequate fit: chi2 (8, N = 1549)=84.22, p<0.05; GFI=0.96, IFI=0.90, CFI=0.90. The antecedent variables accounted for 65% of the variance in the frequency of health promoting behaviors and 53% of the variance in perceived quality of life. The model test supports the hypothesis that quality of life is the outcome of a complex interplay between contextual factors (severity of impairment), antecedent variables, and health promoting behaviors. It also suggests that the relationships among these variables are similar in samples of persons with two different chronic conditions. Further research using a qualitative approach is needed to clarify other contributors to quality of life in persons with post-polio syndrome.

High intensity physical group training in water—an effective training modality for patients with COPD

The aim of this study was to examine the effect of high intensity physical group training in water and on land for patients with COPD with regard to physical capacity and health related quality of life (HRQoL). A controlled, semi-randomised study was conducted where 30 patients were randomised to training either in water or on land. Thirteen patients constituted a control group. Forty-three outpatients, with moderate to severe COPD (27w/16m), from two local hospitals in northern Sweden, were included in the study. High intensity physical group training in water (water group) or on land (land group) was performed for 12weeks, three times per week, 45min per session. The control group received no intervention. Pre- and post-intervention, all patients performed incremental and endurance shuttle walking tests (ISWT and ESWT), cycle ergometer tests and responded questionnaires about HRQoL (St. Georges Respiratory Questionnaire--SGRQ and SF-36). The patients trained with a mean heart rate of 80-90% of peak heart rate. Both training groups increased the distance walked, i.e. land group in ISWT (25m) and water group in ESWT (179m). The water group increased the distance in ESWT significantly more that both the land and the control groups. Both training groups increased the time cycled (40-85s) and work load (10-20W) in the cycle ergometer test. The control group deteriorated in HRQoL according to total score in SGRQ while the training groups remained constant. The water group improved their activity score in SGRQ and their physical health score in SF-36 and those improvements were significant as compared to the land and the control groups. In conclusion, high intensity physical group training in water is of benefit for patients with COPD. It was in some areas found to be even more effective regarding improvements in physical capacity and experienced physical health compared to the same kind of training on land.

Post-Polio Syndrome

Post-polio syndrome (PPS) is the term used for the new late manifestations that occur in patients 30 to 40 years after the occurrence of acute poliomyelitis. PPS has been recognized for over 100 years, but is more common at the present time because of the large epidemics of poliomyelitis in the 1940s and 1950s. PPS is manifested by neurologic, musculoskeletal, and general manifestations. Neurologic manifestations include new weakness, muscle atrophy, dysphagia, dysphonia, and respiratory failure. Musculoskeletal manifestations include muscle pain, joint pain, spinal spondylosis and scoliosis, and secondary root and peripheral nerve compression. General manifestations include generalized fatigue and cold intolerance. New muscle weakness of a mild-to-moderate degree responds well to a nonfatiguing exercise program and pacing of activity with rest periods to avoid muscle overuse. Generalized fatigue may be treated with energy conservation and weight loss programs and lower extremity orthoses. Pharmacologic agents also may be helpful, but have not been beneficial in controlled trials. Bulbar muscle weakness includes dysphagia, dysphonia, sleep disorders, and chronic respiratory failure. Dysphagia may be improved with instruction on compensatory swallowing techniques. Dysphonia is treated with voice exercise therapy and voice amplification devices. Sleep disorders are treated similarly to sleep disorders in non-PPS patients. Respiratory failure may be treated with continuous positive airway pressure, bilevel positive airway pressure, and nasal ventilation, or tracheotomy and permanent ventilation if necessary. Musculoskeletal (muscle and joint) pain is treated with weight loss, pacing of activities, use of assistive devices, and prescribing anti-inflammatory medications and physical therapy techniques. Cardiopulmonary conditioning can be improved without muscle overuse with cycle or arm ergometer exercise or dynamic aquatic exercise.

A pilot study of falls, fear of falling, activity levels and fall prevention actions in older people with polio

BACKGROUND AND AIMS

Polio survivors are ageing, and reporting new complications including falls. The aims of this study were: 1) to determine the frequency of falls, circumstances surrounding them, and the consequences of falls in older people who have polio; and 2) to investigate the range of fall prevention interventions undertaken to reduce the individual's risk of falling.

METHODS

A survey was conducted of members of the Eastern Polio Support Group of Victoria. Twenty-eight respondents (70%; 7 male, 21 female) had a mean age of 66 years and an average duration of 57 years since the onset of polio. The survey addressed demographic data, mobility, frequency and description of falls over the last 12 months, their consequences, and community services utilized. The Modified Falls Efficacy Scale (MFES) and Human Activity Profile (HAP) were also completed. Comparative data on the MFES and HAP were obtained from age- and gender-matched healthy community-dwelling older people.

RESULTS

Fourteen respondents (50%) reported one or more falls over the past 12 months, half reporting multiple falls. Two-thirds of falls occurred while walking. Of those who fell, 67% did not require medical attention. The highest percentage of injuries were bruises or grazes (44%), with one fracture reported. Sixty-one percent reported being fearful of falling, with an average MFES of 7.4 (+/-2.0), compared with the average of 9.7 (+/-0.5) for the age- and gender-matched controls (p<0.05). Only 5 of the respondents reported changing their level of activity as the result of a fall. A significant difference was identified on the Adjusted Activity Score (AAS) of the HAP between polio non-fallers (mean 56.3+/-19.1), polio fallers (mean 40.1+/-15.6) and age- and gender-matched controls (mean 73.5+/-10.3) (F2,46=25.5, p=0.000). The median number of fall prevention activities undertaken in the previous 12 months was one, 11 of the 28 respondents undertaking two or more. The most common interventions implemented were vision checks (42%) and review of medications by a doctor (25%).

CONCLUSIONS

A high rate of falling, fear of falling and low activity levels exist in older people with polio. There is a need for further research and clinical programs to reduce falls and injuries in this group.

A comparison of 4 questionnaires to measure fatigue in postpoliomyelitis syndrome

OBJECTIVE

To assess the comparability and reproducibility of 4 questionnaires used to measure fatigue in postpoliomyelitis syndrome (PPS).

DESIGN

Repeated-measures at a 3-week interval.

SETTING

University hospital.

PARTICIPANTS

Convenience sample of 65 patients with PPS.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

The Fatigue Severity Scale (FSS), the Nottingham Health Profile (NHP) energy category, the Polio Problem List (PPL) fatigue item, and the Dutch Short Fatigue Questionnaire (SFQ).

RESULTS

Correlations of scores between questionnaires were all significant (P<.01) and ranged from.43 (between the NHP energy category and the PPL fatigue item) to.68 (between the PPL fatigue item and the SFQ). Scores on the second visit, normalized to a 0 to 100 scale, were: FSS, 78+/-15; NHP energy category, 47+/-35; PPL fatigue item, 81+/-17; and SFQ, 65+/-22. Except for the difference between the FSS and the PPL fatigue item, the differences in scores between the questionnaires were significant (P<.01). Scale analysis indicated that all questionnaires measured the same unidimensional construct. The reproducibility of the FSS, the PPL fatigue item, and the SFQ was moderate. The smallest detectable change was 1.5 points for the FSS, 2.0 points for the PPL fatigue item, and 1.9 points for the SFQ.

CONCLUSIONS

Although the questionnaires measure the same fatigue construct in PPS, the results are not interchangeable because the ranges of measurement differ. The NHP energy category, in particular, appeared to have a high detection threshold. The moderate reproducibility of the questionnaires indicates a lack of precision, especially when applied at the individual patient level.

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.