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

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.

The value of a post-polio syndrome self-management programme

Background

Post-polio syndrome is characterised by symptoms of fatigue, pain and new-onset neuromuscular weakness, and emerges decades after the initial poliovirus infection. We sought to evaluate the only post-polio syndrome specific self-management programme in the United Kingdom.

Methods

This was a retrospective study of patients who had completed a residential self-management programme led by a multi-disciplinary clinical team. Following a confirmed diagnosis of post-polio syndrome by rehabilitation and neurology specialists, patients were offered to participate in the programme. Although group-based, patients also received individually tailored support on physical exercise and fatigue management. Physical effects, physical function, psychosocial well-being measures were assessed at baseline and 6 months follow-up. Knowledge was tested at baseline and immediately following the programme. Statistical comparisons were made using paired t-test and Wilcoxon signed rank test according to the data distribution.

Results

Over a period of 17 years, 214 participants (median age 61.3 years old, 63% female) attended 31 programmes. At 6 months the following post-polio syndrome specific symptoms improved significantly: fatigue, as measured by the Multidimensional Assessment of Fatigue scale [37.6 (7.1) vs. 34.2 (9.3), P=0.005]; and pain [15.0 (6.1) vs. 13.1 (6.7), P=0.001], atrophy [10.0 (8.0–12.0) vs. 9.0 (7.0–11.0), P=0.002] and bulbar symptoms [3.0 (1.0–5.0) vs. 2.0 (0–4.0), P=0.003] as measured by the Index of Post-polio Sequelae scale. Knowledge related to post-polio syndrome also significantly increased [14.0 (11.0–16.0) vs. 17.0 (16.0–19.0), P=0.001]. Participants were able to walk at a faster speed over 10 meters [0.77 (0.59–1.00) vs. 0.83 (0.67–1.10) m/s, P=0.003] and walked longer distances during the 2-minute walk test [76.9 (31.7) vs. 82.0 (38.4) m, P=0.029]. Depression and anxiety scores did not change over time [PHQ-9, 2.0 (0.3–10.8) vs. 2.0 (0.3–6.8), P=0.450; GAD-7, 2.0 (0–7.0) vs. 1.0 (0–3.0), P=0.460] nor was there change in self-reported quality of life {60 [50–70] vs. 60 [55–70], P=0.200}.

Conclusions

This study suggests that a post-polio syndrome self-management programme led to improvement in symptoms, knowledge and walking speed, but not quality of life. Anxiety and depression scores remained low.

Life Satisfaction in Persons With Late Effects of Polio: A Test-Retest Reliability Study

BACKGROUND

The Life Satisfaction Questionnaire (LiSat-11), including one global item and 10 domain-specific items, is used to evaluate life satisfaction in persons with the late effects of polio (LEoPs). However, there is a lack of knowledge about its psychometric properties.

OBJECTIVE

To evaluate the test-retest reliability of the LiSat-11 and the associations between the global and domain-specific items in persons with LEoPs.

DESIGN

A test-retest design, where data were collected by a postal survey.

SETTING

University Hospital, Outpatient Clinic.

PARTICIPANTS

A cross-sectional sample of persons (20 women and 31 men; mean age 72 years) with LEoPs.

MAIN OUTCOME MEASUREMENTS

LiSat-11, assessing how satisfied a person is with different aspects of life, such as life as a whole, vocation, economy, leisure, contacts with friends and acquaintances, sexual life, activities of daily living (ADLs), family life, partner relationship, somatic health, and psychological health.

METHODS

LiSat-11 was administered on two occasions, 2 weeks apart. The test-retest reliability was evaluated by Kappa statistics, the percent agreement (PA), and the Svensson rank-invariant method. The association between the items was evaluated with the Spearman rank correlation coefficient (rho).

RESULTS

The Kappa coefficients showed good to excellent agreement (0.64-0.90) and the PA ≤1 point was high (>92%) for all items. No items showed any systematic or random disagreements according to the Svensson method. All domain-specific items correlated significantly with the global item "Life as a whole" (P < .01; rhos 0.41 to 0.75).

CONCLUSIONS

LiSat-11 is reliable for assessing life satisfaction in persons with LEoPs. The global item "Life as a whole" is useful as an overall measure but cannot fully replace the information obtained from the domain-specific items of LiSat-11.

Growing up with a disability following paralytic poliomyelitis: experiences from persons with late effects of polio

PURPOSE

To describe the experiences of growing up after acute paralytic poliomyelitis and strategies used to adapt to the new situation.

METHODS

Seven women and seven men (mean age 70 years, min-max 61-78 years) with late effects of polio, who had contracted paralytic polio in their childhood. Data were collected using semi-structured interviews, transcribed verbatim, and analyzed by systematic text condensation.

RESULTS

Memories of contracting acute paralytic poliomyelitis involved being immobilized and sent away from home for surgical and physiotherapeutic treatment. Growing up in a social context that was often tough and unfriendly resulted in the development of strategies, such as optimistic thinking, trying to blend in, trusting one's ability to manage, and to handle the preconceptions and expectations of others. At the onset of late effects of polio, some of these strategies were still functioning, whereas overachieving, disregarding pain, and weariness were not.

CONCLUSION

The challenges of growing up with a disability following paralytic polio led to the development of various psychological strategies for managing daily life. By understanding these experiences and strategies, knowledge may be gained in assisting rehabilitation professionals to better support persons with late effects of polio in adapting to the new situation.Implications for rehabilitationAt the onset of late effects of polio, strategies developed earlier in life, such as overachieving, disregarding pain, and weariness, may not function anymore.Understanding the experiences of growing up with poliomyelitis can support rehabilitation professionals to provide targeted interventions for people with late effects of polio and enable them to develop new adaptive strategies.Developing new strategies, such as accepting increased symptoms, and augmenting self-esteem and self-efficacy, may improve daily functioning among people with late effects of polio.

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.

Age- and Sex-Related Differences in Motor Performance During Sustained Maximal Voluntary Contraction of the First Dorsal Interosseous

Age and sex affect the neuromuscular system including performance fatigability. Data on performance fatigability and underlying mechanisms in hand muscles are scarce. Therefore, we determined the effects of age and sex on force decline, and the mechanisms contributing to force decline, during a sustained isometric maximal voluntary contraction (MVC) with the index finger abductor (first dorsal interosseous, FDI). Subjects (n = 51, age range: 19–77 years, 25 females) performed brief and a 2-min sustained MVC with the right FDI. Abduction force and root mean squared electromyographic activity (rms-EMG) were recorded in both hands. Double-pulse stimulation was applied to the ulnar nerve during (superimposed twitch) and after (doublet-force) the brief and sustained MVCs. Compared to females, males were stronger (134%, p < 0.001) and exhibited a greater decline in voluntary (difference: 8%, p = 0.010) and evoked (doublet) force (difference: 12%, p = 0.010) during and after the sustained MVC. Age did not affect MVC, force decline and superimposed twitch. The ratio between the doublet- and MVC-force was greater in females (0.33, p = 0.007) and in older (0.38, p = 0.06) individuals than in males (0.30) and younger (0.30) individuals; after the sustained MVC this ratio increased with age and the increase was larger for females compared to males (p = 0.04). The inadvertent contralateral, left force and rms-EMG activity increased over time (2.7–13.6% MVC and 5.4–17.7% MVC, respectively). Males had higher contralateral forces than females (p = 0.012) and contralateral force was higher at the start of the contralateral contraction in older compared with young subjects (difference: 29%, p = 0.008). In conclusion, our results suggest that the observed sex-differences in performance fatigability were mainly due to differences in peripheral muscle properties. Yet the reduced amount of contralateral activity and the larger difference in evoked versus voluntary force in female subjects indicate that sex-differences in voluntary activation should not be overlooked. These data obtained in neurological healthy adults provides a framework and help the interpretation and referencing of neurophysiological measures in patients suffering from neuromuscular diseases, who often present with symptoms of performance fatigability.