Lincolnshire Post-Polio Library - A Service of The Lincolnshire Post-Polio Network
The late effects of Polio Information for Health Care Providers
Charlotte Leboeuf

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15 MANAGING THE LATE EFFECTS OF POLIO - PRACTICAL ASPECTS

There is no well documented evidence for the management of the late effects of polio. The information included in this text reflects the state of present thinking.

1. CARING FOR THE CARERS

Changes to the equilibrium of the family can have profound effects on all of its members. Not only the person who experiences the symptoms needs assistance; the carers also indirectly experience the late effects of polio. The important role of the carers needs to be recognised. They are significant members of the management team, who can participate at their full potential only if they are fully informed of the situation and allowed to be actively involved in clinical decision making and management.

The need for recreation and rest among carers must also be recognised. Carers are no saints; they have the right to experience "negative" emotions. Caring for the carer should be part of caring for the person who experiences the late effects of polio.

2. CHEST INFECTIONS

Whenever hypoventilation is a problem, frequent and/or severe chest infections may occur. In some instances prophylactic antibiotics may be prescribed e.g. during the winter months. In all cases of chest infection, specimens should be taken to guide the choice of antibiotic therapy. Vaccination against influenza and pneumonia is advised.

Smoking must be totally given up, including passive smoking.

3. ENERGY CONSERVATION

Energy conservation is thought to prevent and combat weakness and fatigue due to physical overuse. By saving on energy in everyday activities it may be possible to put it to use in better ways.

-   Objectively review work routines.
-   Set priorities for all activities.
-   Establish suitable changes to work routines.
-   Plan and space unavoidable activities which lead to fatigue.
-   Plan for recovery time, rest and recreation.
-   Assess the need for energy saving equipment.
-   Make improvements to the environment which result in decreased energy expenditure and increased independence.

Appropriate professional assessment is essential before purchasing and using any special equipment. Regular monitoring is also recommended. The Independent Living Centre in each state (see Independent Living Centres in section 16) can advise on a wide range of equipment.

4. EXERCISE AND FITNESS TRAINING

Inactivity leads to deconditioning, which is a cause of weakness and fatigue. Physical inactivity is commonly considered a contributing factor to several degenerative disorders such as heart disease, diabetes and osteoarthrosis. It also has a deleterious effect on weight control and digestion.

Much has been written on the dangers of overtraining post-polio muscles. This is generally believed to be a cause of additional weakness and fatigue. It is therefore considered important to balance activity and rest. Training goals need to be set which take into account the degree of disability, age and lifestyle. Some correction of muscle imbalance is possible with training and guidance.

Most people who had polio are left with few if any obvious residual problems. Many do not experience any signs of the late effects of polio. Their life style may include physical exercise. Nevertheless, they probably need to be careful to avoid overuse fatigue.

Non-fatiguing exercise programs are advocated for people who already experience the late effects of polio. Walking, jogging, cycling, golfing, swimming and gymnasium work may be suitable, providing that the work is carried out carefully. Increases in such physical activities should be gradual and should stop short of pain, weakness or increased fatigue.

The goal is to improve strength and endurance in underused muscles. These exercises can be designed as follows (1,2):

-   Determine the amount of weight that can be moved without pain or fatigue.
-   Determine the number of repititions through which this weight can be moved.
-   Start the strengthening program at 50-60% of the determined values, gradually increasing the weight and the repititions without causing pain or weakness.

A modified aerobic training program can be designed in a similar manner (3). The goal is to improve the cardiopulmonary capacity. Walking, cycling and swimming are considered suitable, providing that:

-   the work is carried out below capacity;
-   it is increased gradually;
-   it does not cause increased weakness, undue fatigue or discomfort.

Respiratory monitoring sometimes may be necessary to prevent difficulties due to overuse of respiratory muscles.

Jones et al (3) concluded that a 16 week modified aerobic exercise program (exercise three times per week at 70% of maximal heart rate) is safe. Cardiopulmonary fitness improved more in the test group than in the control group.

Other possible alternatives are:

Water exercises are particularly suitable for people with marked residual weakness and movement disability. The warm water reduces muscle tension. Gravity ceases to be a problem, and the venous return improves in affected limbs.

It is possible to use the resistance and the assistance of the water to create a non-traumatic endurance program (4), which has been shown to improve fitness in severely disabled people (5). Hydrotherapy can combine exercise with stretches, postural exercises, massage, relaxation and fun.

Guidance from professional personnel is essential for safety reasons and to obtain maximum benefit.

Water sports, such as scuba diving, provide freedom to move without assistive devices (6). Caution needs to be exercised in underwater activities in cases of obvious or latent paresis of the palate or pharynx in order to avoid drowning. Although gag and swallowing reflexes appear normal they may become inadequate when stressed under water (7).

Flexibility exercises, gentle stretching and yoga may be suitable alternatives to keep and improve flexibility of stiff muscles and joints.

Whether training is necessary and suitable at all in post-polio people is controversial, but the consensus is clear on the need to curtail physical activities if fatigue, muscle weakness or pain occurs. It is preferable to seek professional assistance, which should include careful assessment of neuromuscular, articular and respiratory functions, before embarking on a training programme.

5. PAIN CONTROL

Since little is known about the relative indications and success rates for various therapies associated with the late effects of polio, most people will have to learn how to manage their chronic and intermittent pain themselves.

Westbrook's survey of members of Australian post-polio support groups showed that they consulted many different types of health care providers, with very mixed results (8). Obviously, each person is a specific entity who requires individual assessment and treatment.

The treatment may range from the more technical (TENS, surgery) to the simplistic. Warmth and massage may have a beneficial effect on circulation, cramp and contracted muscles, but may be unsuitable in muscles which are inflamed.

Pain killers may be necessary to sleep at night. Light exercises (including hydrotherapy) may have a positive effect on chronic pain.

Mild inflammation may respond favourably to simple measures, such as ice and rest, whereas severe inflammation may require anti-inflammatory treatment.

Manipulation and mobilisation (1) may reduce pain due to articular stiffness and immobility, but it may aggravate pain in joints which are hypermobile, severely inflamed or subjected to extreme stress.

6. ORTHOTIC SUPPORTS AND ORTHOPAEDIC MANAGEMENT

Unequal limbs, hyperextended knee, scoliosis, drop foot and paralysed limbs are the most common types of residual polio problems which require orthotic support (orthosis) .

The purposes of orthoses in post-polio management are to control motion and support joints which have lost their normal muscle control and to help prevent the development of fixed deformities. Orthotic supports may be essential for effective ambulation. They are most frequently applied for lower limb muscle weakness and anatomical joint mal-alignment. Although less common, orthoses may also be applied for spinal, upper limb and abdominal muscle weaknesses.

The degree of dysfunction and the available orthotic management vary. Individual assessment is necessary to ascertain specific needs. Orthotists perform orthotic assessment and provide orthoses. They also prescribe orthopaedic footwear. Podiatrists may have involvement in treating foot disorders, prescribing footwear and fitting foot supports. Orthopaedic shoe makers provide custom-made shoes.

Regular re-assessment is essential.

People with marked residual problems from polio probably make the most use of orthoses. Since most polio-affected areas have retained sensation, comfort is of great importance. This group tends to be self-reliant in the management of orthotic devices.

People with mild or moderate residual problems are more likely to have discarded orthoses when young, in the belief that they would never be needed again. If their condition deteriorates with marked weakness, it is important that they seek assistance before irreversible damage has occurred to muscles and joints. An example is the degenerative changes, deformity and pain which eventually occur in knee joints which become hyperextended due to the lack of protection from adequate muscles.

The problems of facing a second disability will probably result in coping difficulties and a more demanding attitude to the aesthetic effect of any orthotic equipment. Counselling and support may be required to (re)introduce the use of supportive equipment and during the "running-in" period.

Many people who need orthotic support probably make do without, due to the considerable costs for those not eligible under various assistance programmes. The same difficulties arise when changes or replacement are necessary.

Surgical procedures may sometimes be necessary. The orthopaedic surgeon is the appropriate person to evaluate persistent pain and gross fixed deformities.

    Useful reading:
  1. Perry J, Fleming C. Polio: Long-term problems. Orthopaedics 1985;8:877-8. [PubMed Abstract]
  2. Waring WP, Maynard F, Grady W et al. Influence of appropriate lower extremity orthotic management on ambulation, pain, and fatigue in a postpolio population. Arch Phys Med Rehabil 1989;70:371-5. [PubMed Abstract]

7. PLANNING THE ENVIRONMENT FOR ENERGY CONSERVATION

When planning the environment for energy conservation it is important to consider ease of use and safety. Each individual has particular requirements. It may be necessary to improvise, particularly in private dwellings.

Australian building requirements regarding design for access and mobility (Australia Standard 1428) can be obtained from the Standards Association of Australia. They may be consulted through architects and Local Government building surveyors.

8. POST-SURGICAL PRECAUTIONS

Following general anaesthesia people with a history of bulbar polio may take longer to regain normal respiration and thus need additional surveillance during the post-anaesthetic recovery period.

Many people report prolonged fatigue and weakness following immobility e.g. associated with surgery. It is important to take this into account during the convalescent period.

9. POSTURE CHANGES

It may be necessary to improve body mechanics through active postural changes or supportive devices. Chiropractors, occupational therapists, orthopaedic surgeons, orthotists, physiotherapists and podiatrists are professionals who may be able to assist in this area.

10. PSYCHOLOGICAL SUPPORT

Clinical management may be most successful when the patient has the ability to deal successfully with the various problems which may arise from the late effects of polio.

Psychological support may be necessary. Increased fatigue and weakness may make it difficult to cope with daily activities and personal relationships. Visible signs of disability may be difficult to accept. The necessity to curtail activities prematurely may cause grief and a feeling of diminished social value. There may be resultant financial hardship.

11. RELAXATION AND STRESS MANAGEMENT

Guidance relating to relaxation and stress management may be useful in improving the quality of periods of rest.

12. RESPIRATORY ASSISTANCE

If respiration becomes a problem, it is necessary to assess the situation very carefully. Chronic hypoventilation, especially when progressive, causes hypoxia and frequent pulmonary infections. Signs of hypoxia are breathlessness, lassitude and intellectual impairment. Nocturnal hypoxia may also manifest itself as insomnia, morning headaches, morning confusion and day time sleepiness. People who require respiratory assistance may do so occasionally (e.g. following physical efforts or during chest infections), regularly, but for short periods, or more or less constantly.

There are two main types of ventilators. Negative pressure ventilators, such as the iron lung, the rocking bed, the portalung, the pulmowrap, the cuirass and the pneumobelt, assist in the expiratory phase. Positive pressure ventilators provide support for inspiration. Previously, a tracheostomy was necessary with positive pressure ventilators, with the implications of an invasive procedure. Recently nose or face masks have become available. Specialist advice should be sought.

Severity of condition, life style, fit of equipment, portability and need for free use of the mouth are some of the factors which will determine the individual suitability of various ventilators.

A thoracic physiotherapist can assist with breathing exercises. It is important to remember that overuse of respiratory muscles may aggravate respiratory weakness.

    Useful reading:
  1. Yang GF, Alba A, Lee M, Khan A. Pneumobelt for sleep in the ventilator user: Clinical experience. Arch Phys Med Rehabil 1989;70:707-11. [PubMed Abstract]
  2. Bach JR, Alba SA, Bohatiuk G et al. Mouth intermittent positive pressure ventilation in the management of postpolio respiratory insufficiency. Chest 1987;91:859-64. [PubMed Abstract]

13. SOCIAL AND MEDICAL DRUGS

Social and medical drugs may have a depressive effect on the central functions of the brain. If such substances have been taken, extra caution is necessary at night to prevent deterioration of respiration.

Unstable joints are more at risk following use of muscle relaxants. If the gait is unstable, it is wise to take extra precautions.

The use of alcohol may be inappropriate for people who already experience problems with gait.

The New Zealand Polio Support Groups have issued a drug alert card which warns against the following substances, which "should be avoided or used with caution":

14. WEIGHT REDUCTION

Weight reduction may be necessary in order to conserve energy. Being overweight may add extra stress to muscles and joints.

In order to lose weight it is usually necessary to maintain or increase the energy expenditure while reducing the intake of total calories. A dietitian/nutritionist can help work out a suitable nutritional approach based on lifestyle and dietary habits.

Any increase in energy expenditure requires careful evaluation, planning and follow-up to avoid further overuse of the neuromuscular system.

References:

  1. Feldman RM. The use of strengthening exercises in post-polio sequelae. Methods and results. Orthopedics 1985;8:889-90. [PubMed Abstract]
  2. Owen RR, Jones D. Polio residuals clinic: Conditioning exercise program. Orthopedics 1985;8:882-3. [PubMed Abstract]
  3. Jones DR, Speir J, Canine K et al. Cardiorespiratory responses to aerobic training by patients with postpoliomyelitis sequelae. JAMA 1989;261:3255-8. [PubMed Abstract]
  4. Jenkins L. A hydrotherapy program for patients with post-polio syndrome. Polio Network News 1990;6:15-8.
  5. DiRocco P, Hashimoto A, Daskalovic I, Langbein E. Cardiopulmonary reponses during arm work on land and in a water environment of nonambulatory spinal cord impaired individuals. Paraplegia 1985;23:90-9. [PubMed Abstract]
  6. Madorsky JG, Madorsky AG. Scuba diving: taking the wheelchair out of wheeelchair sports. Arch Phys Med Rehabil 1988;69:215-8 (abstract). [PubMed Abstract]
  7. Rubin AM, Blair RL, Alberti PW. Near-drowning, scuba diving: an unusual late sequela of bulbar polio. J Laryngol Otol 1984;98:733-6 (abstract) [PubMed Abstract]
  8. Westbrook MT. Clients' evaluations of chiropractic management for post polio syndrome. J Aust Chiropractors' Assoc (In press).

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Copyright The Lincolnshire Post-Polio Network 1997 - 2010.

This document comprises an index, foreword, introduction and seventeen other sections or subdocuments. Permission for printing copies is granted only on the basis that ALL sections are printed in their entirety and kept together as a single document.

Document preparation: Chris Salter, Original Think-tank, Cornwall, United Kingdom.
Created: 7th July 1997
Last modification: 20th January 2010.
Last information content change: 6th June 2000

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