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Catalogue

For Medical Professionals

The section Advise your Doctors of the Catalogue For the Polio Survivor, Friends and Family includes articles (for medical professionals) additional to those listed here, Non-Paralytic Polio and PPS being one significant example. We cannot emphasise enough that medical professionals should read the articles in that section as well as those below.

IMPORTANT NOTES FOR FIRST-TIME READERS

Catalogue Entry Index

Select title in catalogue entry index to display summary details of article, select title in summary to display full text of article

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[ Catalogue Index ]

Polio and Post-Polio Primers

Title: Pathophysiology and diagnosis of post-polio syndrome
[ Full Text Here ] Author(s): Daria A. Trojan, Neil R. Cashman
Original Publication: NeuroRehabilitation 8 (1997) 83-92
Abstract/Extract: Post-poliomyelitis syndrome is defined as a clinical syndrome of new weakness, fatigue and pain which can occur several decades following recovery from paralytic poliomyelitis. The cause of this disorder is still unclear, and many possible etiologies have been proposed. The most widely accepted etiology was first proposed by Wiechers and Hubbell, which attributes PPS to a distal degeneration of massively enlarged post-polio motor units. Other probable contributing factors to the onset of this disease are the ageing process, and overuse. Currently, there is no specific diagnostic test for PPS, which continues to be a diagnosis of exclusion in an individual with symptoms and signs of the disorder. © 1997 Elsevier Science Ireland Ltd.

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Title: Poliomyelitis
[ Full Text Here ] Author(s): D Kidd, AJ Williams, RS Howard
Original Publication: Postgraduate Medical Journal 1996; 72: 641 - 647
Abstract/Extract: 1996 is polio awareness year. This paper reviews the clinical syndrome of acute paralytic poliomyelitis and its sequelae. We discuss epidemiological studies of the syndrome of late functional deterioration many years after the acute infection and the current hypotheses of the pathophysiology of such disorders. Recent evidence has suggested that potentially treatable factors may be implicated in the majority of such patients and it is therefore important to exclude such disorders before attributing late functional deterioration to progressive postpolio muscular atrophy.

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Title: Poliomyelitis and the Post-Polio Syndrome
[ Full Text Here ] Author(s): Burk Jubelt and Judy Drucker.
Original Publication: Chapter 34. Reprinted from Motor Disorders edited by David S. Younger.
Lippincott Williams & Wilkins, Philadelphia © 1999
Abstract/Extract: In the first half of the this century, epidemics of poliomyelitis (polio) ravaged the world. In the epidemic of 1952, over 20,000 Americans developed paralytic polio. With the introduction of the Salk inactivated polio vaccine (IPV) in 1954 and the Sabin oral polio vaccine (OPV) in 1961, the number of paralytic cases decreased to a handful per year. Polio had vanished and no longer was on the consciousness of Americans. The elimination of polio was a tremendous achievement for science and American medicine. However, in the late 1970s, survivors of paralytic polio began to notice new health problems that included fatigue, pain, and new weakness, thought not to be "real" by the medical establishment. The term "post-polio syndrome" (PPS) was coined by these patients to emphasize their new health problems. This chapter reviews acute poliomyelitis and the related PPS.

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Title: Post-Polio Sequelae: Physiological and Psychological Overview
[ Full Text Here ] Author(s): Nancy M. Frick, M. Div. and Richard L. Bruno, Ph.D.
Original Publication: Rehabilitation Literature, 1986; 47 (5-6): 106-111.
Abstract/Extract: When the Salk and Sabin vaccines brought an end to the annual summer nightmare of polio epidemics, most Americans simply forgot about polio. Even many of those who had paralytic poliomyelitis put the disease out of their minds once they had achieved maximum recovery of function. Unfortunately, polio has again forced itself into the nation's consciousness. Over the past five years, many of those who had polio have been experiencing new and unexpected symptoms that range in severity from being merely unpleasant to severely debilitating:

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Title: Post-Polio Syndrome: Pathophysiology and Clinical Management
[ Full Text Here ] Special Note: This is a long article (226K). We have also produced a multi-document version comprising fifteen separate shorter documents which reflect the section headings of the original article. Multi-document Version
Author(s): Anne Carrington Gawne and Lauro S. Halstead.
Original Publication: Critical Reviews in Physical and Rehabilitation Medicine, 7(2):147-188 (1995).
Abstract/Extract: Post-polio syndrome (PPS) is a progressive neuromuscular syndrome characterized by symptoms of weakness, fatigue, pain in muscles and joints, and breathing and swallowing difficulties. Survivors of poliomyelitis experience it many years after their initial infection. Although the etiology for these symptoms is unclear, it may be due to motor unit dysfunction manifested by deterioration of the peripheral axons and neuromuscular junction, probably as result of overwork. An estimated 60% of the over 640,000 paralytic polio survivors in the U.S. may suffer from the late effects of polio. Their physical and functional rehabilitation care presents a challenge for practitioners in all disciplines. To evaluate these symptoms, a comprehensive assessment must be done, as frequently PPS is a diagnosis of exclusion. Care of the patient with PPS is best carried out by an interdisciplinary team of rehabilitation specialists. This article reviews the epidemiology, pathophysiology, characteristics, assessment, and rehabilitation care of the patient with PPS.

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Title: Predictive Factors for Post-Poliomyelitis Syndrome
[ Full Text Here ] Author(s): Daria A. Trojan, MD, MSc, Neil R. Cashman, MD, Stanley Shapiro, PhD, Catherine M. Tansey, MSc, John M. Esdaile, MD
Original Publication: Arch Phys Med Rehabil Vol 75, July 1994, 770-777
Abstract/Extract: Post-poliomyelitis syndrome (PPS) is generally defined as a clinical syndrome of new weakness, fatigue, and pain in individuals who have previously recovered from acute paralytic poliomyelitis. The purpose of this study was to identify, through a case-control study design, factors that predict subsequent PPS in patients with prior paralytic poliomyelitis. Among patients attending a university-affiliate hospital post-polio clinic, "cases" were patients with new weakness and fatigue, and "controls" were patients without these complaints. A chart review of 353 patients identified 127 cases and 39 controls. Logistic regression modeling was used to calculate adjusted and unadjusted odds ratios. In univariate analyses, significant risk factors for PPS were a greater age at time of presentation to clinic (p=0.01), a longer time since acute polio (p=0.01), and more weakness at acute polio (p=0.02). Other significant associated, but not necessarily causal factors were a recent weight gain (p=0.005), muscle pain (p=0.01) particularly that associated with exercise (p=0.005), and joint pain (p=0.04). Multivariate analyses revealed that a model containing age at presentation to clinic, severity of weakness at acute polio, muscle pain with exercise, recent weight gain, and joint pain best distinguished cases from controls. Age at acute polio, degree of recovery after polio, weakness at best point after polio, physical activity, and sex were not contributing factors. These findings suggest that the degree of initial motor unit involvement as measured by weakness at acute polio, and possibly the aging process and overuse are important in predicting PPS.
© 1994 by the American Congress of Rehabilitation Medicine and the American Academy of Physical Medicine and Rehabilitation

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Population Surveys

Title: Changes in Post-Polio Survivors Over Five Years: Symptoms and Reactions to Treatments.
[ Full Text Here ] Author(s): Mary T. Westbrook, PhD
Original Publication: Proceedings of the 12th World Congress, International Federation of Physical Medicine and Rehabilitation, Sydney, March 1995.
Abstract/Extract: A group of 176 people with post-polio syndrome, identified using Ramlow et al's (1992) criteria, took part in a 5 year follow-up survey. Most reported increased muscle weakness (91%), fatigue (91%), muscle pain (80%), joint pain (64%) and changes in walking (60%). Increases in other symptoms occurred in less than half the group. Cramps, sensitivity to cold, muscle atrophy and muscle twitching were the symptoms most likely to have stabilised. The average respondent reported greater difficulty in carrying out 4 of the 8 activities of daily living investigated. Respondents were significantly less anxious and depressed about their condition at follow-up. Degree of post-polio changes reported at the time of the first survey was a better predictor of decline during the five years than were initial polio histories or psycho-social variables. Health practitioners most likely to have been consulted were general practitioners and physiotherapists. Specialists in rehabilitation medicine were rated as providing more beneficial treatment than other medical practitioners. Treatments reported to provide good symptom relief included massage and water activities but not exercise. Life style modifications associated with pacing, reduced activity and rest were particularly effective. Overall 68% of respondents considered there was much they could do to control post-polio symptoms.

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Title: Health and Demographic Characteristics of Polio Survivors
[ Full Text Here ] Author(s): Sandra S. French and G. Sam Sloss
Original Publication: Lincolnshire Post-Polio Library April 1999.
Abstract/Extract: Since 1985, the Louisville and Ashland, Kentucky chapters of the Polio Survivors Organization have collected questionnaire data from polio survivors. The questionnaires included data on Social and demographic data - e.g., age, sex, education, and employment history; Polio history - e.g., dates, types, and treatments; and Current health problems - e.g., fatigue, depression, and breathing problems. Respondents include people from the east coast to the west coast and from states bordering both Canada and Mexico. The 295 respondents live in 202 different zip code areas with no more than three people from any one zip code. This article reports on the data from this sample of polio survivors.

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Title: A Qualitative Survey of Postpolio Syndrome in the Leeds area
[ Full Text Here ] Author(s): S. A. Arshad, St. Mary's Hospital, Greenhill Road, Leeds.
Original Publication: Lincolnshire Post-Polio Library 2000.
Abstract/Extract: A qualitative study was carried out between the months of September and November 1998. Interviews were done on 14 patients suffering from the post-polio syndrome. They were between the ages of 40 and 72 years and eight males and six females. All of them had polio in childhood, before the age of 10 years with various impairments. The aim of this study was to explore possible influences on the perceived quality of life for people with PPS. This is a pilot case series in descriptive epidemilogy.

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Title: A Report Into The Consequencies Of Living With Polio For 63,500 Years
[ Full Text Here ] Author(s): Peter Field
Original Publication: 1995
Abstract/Extract: This survey was conducted as a lay study into the impact on the lives of people who had polio earlier in life, and also to establish the frequency as well as the severity of the problems attributed to the "Late Effects of Polio".

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Title: Survey of the Late Effects of Polio in Lothian
[ Full Text Here ] Author(s): B. Pentland, D. J. Hellawell, J. Benjamin, R. Prasad
Original Publication: Rehabilitation Studies Unit, Charles Bell Pavilion, Astley Ainslie Hospital, 33 Grange Loan, Edinburgh EH9 2HL. January 1999
Abstract/Extract: The Edinburgh Branch of the British Polio Fellowship (BPF) expressed the concern of members that the medical and related professions often appeared unfamiliar with the late consequences of polio and that services were not meeting their needs. In an attempt to determine the number of people affected and the nature of their experience, this postal survey was done in 1998. A set of questionnaires were sent to 221 people, in Edinburgh and the Lothians, who had been identified as suffering polio in the past from those known to the BPF and hospital records. There were 125 replies which constituted the study population: 60% were female; the median age was 59 years; and the median time since original diagnosis was 51 years.

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Title: Post-Polio Population Statistics - A Review
[ Full Text Here ] Author(s): Chris Salter, Vice-Chairman, Lincolnshire Post-Polio Network.
Original Publication: A Lincolnshire Post-Polio Library Publication. July 2000
Abstract/Extract:

As can be seen, when trying to determine the number cases of PPS in a population we are confronted with a number of problems.

  1. No current statistics of persons currently diagnosed as PPS.
  2. Estimates of the percentage of cases of prior polio likely to develop PPS vary considerably. Few if any take into account that a historical clinical diagnosis of non-paralytic polio does not preclude a diagnosis of PPS.
  3. Although in recent years records of notified and confirmed cases of polio have been maintained by the World Health Authority, records predating the eradication campaign are more difficult to locate and may be unreliable.
  4. Estimates of the numbers of cases of prior polio vary considerably and as with PPS estimates, tend to be limited to so called paralytic polio. It is worth noting that a 'mild' polio infection may not even be diagnosed at the time of the infection but may still result in sufficient damage to cause problems in later life.

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Post-Polio Patient Management

Title: Managing the Late Effects of Polio from a Life-Course Perspective
[ Full Text Here ] Author(s): Frederick M. Maynard.
Original Publication: Ann N Y Acad Sci 1995 May 25;753:354-360
Abstract/Extract: This paper reviews the implications of recent research investigations for the management of patients with PPS. It proposes that current knowledge supports the view that PPS is a secondary condition frequently occurring during the life course of people with residual motor impairment from paralytic poliomyelitis and does not support the view that PPS is a distinct pathological process which should be labeled a disease or illness.

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Title: Recognizing Typical Coping Styles Of Polio Survivors Can Improve Re-Rehabilitation
[ Full Text Here ] Author(s): Frederick M. Maynard, MD and Sunny Roller, MA
Original Publication: Am. J. Phys. Med. Rehabil. Vol. 70, No. 2, April 1991
Abstract/Extract: During the past ten years many polio survivors in the U.S. have actively been seeking professional help for a wide range of new physical problems, commonly referred to as the late effects of polio. Often these persons require re-rehabilitation in order to continue their accustomed social roles. In our experience at the Post-Polio Program of the University of Michigan Medical Center, we have come to recognize among polio survivors three distinct patterns of emotional reaction to the need for re-rehabilitation. These patterns appear to result from characteristic styles of living with a chronic disability. We propose a model for categorizing polio survivors that is based on our observations. Although it is limited by overgeneralization, we have found that polio survivors themselves have verbally validated our proposed categories at many post-polio conferences. A 1963 study of children with polio and their families also describes early coping behaviors that are compatible with our model.

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PPS Fatigue

Title: The Postpolio Syndrome - An Overuse Phenomenon
[ Full Text Here ] Author(s): Jacquelin Perry, M.D., Gregory Barnes, B.S., R.P.T. and JoAnne K. Gronley, M.A., R.P.T.
Original Publication: Clinical Orthopaedics and Related Research Volume 233:145-162; August 1988
Abstract/Extract: Persons with good recovery of function following their initial poliomyelitis are now, more than 30 years later, experiencing new weakness, fatigue, and muscle pain. The likelihood of muscle overuse being the cause of this late functional loss was investigated by dynamic electromyography (EMG) and foot-switch stride analysis in 34 symptomatic patients. Manual testing grouped the muscles, with strong (S) encompassing Grades Good (G) and Normal (N) while weak (W) included Fair plus (F+) to zero (0). After testing quadriceps and calf strength, the patients fell into one of four classes: strong quadriceps and calf (SQ/SC) strong quadriceps and weak calf (SQ/WC) weak quadriceps and strong calf (WQ/SC) or combined weak quadriceps and calf (WQ/WC). Quantified EMG; (normalized by the manual muscle test EMG) defined the mean duration and intensity of the quadriceps soleus, lower gluteus maximus, and long head of the biceps femoris during walking. Overuse was defined as values greater than the laboratory normal (mean·+ 1 SD). Each muscle exhibited instances of overuse, normalcy, and sparing. The biceps femoris was the only muscle with dominant overuse (82%). Quadriceps overuse was next in frequency (53%). Soleus activity infrequently exceeded normal function (34%), but this still represented more than twice the intensity and duration of the other muscles. Gluteus maximus action was also seldom excessive (34%). The patients averaged two muscles with excessive use during walking. Gait velocity of the SQ/SC strong group was highest (71% of normal) while the three categories that included weak muscles had walking speeds in the range of 50% of normal. The finding of muscle overuse during a single free-speed walking test that does not attain normal velocity supports the concept of muscle overuse being the cause of the patient's dysfunction.

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Title: The Neuroanatomy Of Post-Polio Fatigue
[ Full Text Here ] Author(s): Richard L. Bruno, Ph.D., Jesse M. Cohen, M.D., Thomas Galski, Ph.D. and Nancy M. Frick, M.Div.
Abstract/Extract: Fatigue is the most commonly reported, most debilitating and most poorly understood Post-Polio Sequelae (PPS). Postmortem studies of fifty years ago documented frequent and severe poliovirus-induced lesions within the reticular activating system (RAS). Recently, neuropsychological testing has documented marked attention deficits in polio survivors reporting severe fatigue. However, neither of these findings has been related to the pathophysiology of post-polio fatigue. Magnetic resonance imaging of the brain was performed in 22 polio survivors carefully screened to eliminate the effect of comorbidities. Subjects rated the severity of their daily fatigue and subjective problems with attention, cognition and memory. Small discrete or multiple punctate areas of hyperintense signal (HS) in the reticular formation, putamen, medial leminiscus or white matter tracts were imaged in 55% of the subjects reporting high fatigue and in none those reporting low fatigue. The presence of HS significantly correlated with fatigue severity and subjective problems in attention, concentration, staying awake, recent memory and thinking clearly. The lack of significant correlations between HS or fatigue severity and age, severity of the acute polio, depressive symptoms or difficulty sleeping militates against these factors as either causing HS or producing fatigue. These preliminary findings suggest that poliovirus-induced lesions in the RAS may underlie the subjective fatigue and attention deficits associated with PPS fatigue.

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Title: The Neuropsychology Of Post-Polio Fatigue
[ Full Text Here ] Author(s): Richard L. Bruno, Ph.D., Thomas Galski, Ph.D., John DeLuca, Ph.D.
Original Publication: Archives of Physical Medicine and Rehabilitation, 1993; 74: 1061-1065.
Abstract/Extract: To test the hypothesis that post-polio fatigue and its concomitant cognitive deficits are associated with an impairment of attention and not of higher-level cognitive processes, six carefully screened polio survivors were administered a battery of neuropsychological tests. Only subjects reporting severe fatigue, and not those with mild fatigue, demonstrated clinically significant deficits on all tests of attention, concentration and information processing speed while showing no impairments of cognitive ability or verbal memory. These findings suggest that an impaired ability to maintain attention and rapidly process complex information appears to be a characteristic in polio survivors reporting severe fatigue, since these deficits were documented even when their subjective rating of fatigue was low. This finding supports the hypothesis that a polio-related impairment of selective attention underlies polio survivors' subjective experience of fatigue and cognitive problems.

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Title: The Pathophysiology Of Post-Polio Fatigue:
A Role for the Basal Ganglia in the Generation of Fatigue
[ Full Text Here ] Author(s): Richard L. Bruno, Ph.D., Robert Sapolsky, Ph.D., Jerald R. Zimmerman, M.D., and Nancy M. Frick, Lh.D.
Original Publication: The pathophysiology of a central cause of post-polio fatigue. Annals of the New York Academy of Sciences, 1995; 753: 257-275.
Abstract/Extract: Fatigue is the most commonly reported, most debilitating and least studied Post-Polio Sequelae (PPS) affecting the more than 1.63 million American polio survivors. Post-polio fatigue is characterized by subjective reports of problems with attention, cognition and maintaining wakefulness, symptoms reminiscent of nearly two dozen outbreaks during this century of post-viral fatigue syndromes that are related clinically, historically or anatomically to poliovirus infections. These relationships, and recent studies that associate post-polio fatigue with clinically significant deficits on neuropsychologic tests of attention, histopathologic and neuroradiologic evidence of brain lesions and impaired activation of the hypothalamic-pituitary-adrenal axis, will be reviewed to described a role for the reticular activating system and basal ganglia in the pathophysiology of post-polio fatigue. The possibility of pharmacologic therapy for PPS is also discussed.

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Title: Polioencephalitis and the Brain Fatigue Generator Model of Post-Viral Fatigue Syndromes
[ Full Text Here ] Author(s): Richard L. Bruno, Ph.D., Nancy M. Frick, Lh.D., Susan Creange, M.A., Jerald R. Zimmerman, M.D., and Todd Lewis, Ph.D.
Original Publication: JOURNAL OF CHRONIC FATIGUE SYNDROME, 1996 (in press).
Abstract/Extract: Fatigue is the most commonly reported and most debilitating Post-Polio Sequelae (PPS) affecting millions of polio survivors world-wide. Post-polio fatigue is associated with: 1) subjective reports of difficulty with attention, cognition, word-finding and maintaining wakefulness; 2) clinically significant deficits on neuropsychological tests of information processing speed and attention; 3) gray and white matter hyperintensities in the reticular activating system on magnetic resonance imaging of the brain; 4) neuroendocrine evidence of impaired activation of the HPA axis.

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Title: Anticholinesterase-responsive neuromuscular junction transmission defects in post-poliomyelitis fatigue
[ Full Text Here ] Author(s): Daria A. Trojan, Daniel Gendron and Neil R. Cashman
Original Publication: Journal of the Neurological Sciences, 114 (1993) 170-177
Abstract/Extract: Disabling generalized fatigue and muscle fatiguability are common features of post-poliomyelitis syndrome (PPS). In 17 fatigued PPS patients, we measured jitter on stimulation single-fiber electromyography (S-SFEMG) for at least 3.5 min before and after i.v. injection of 10 mg edrophonium. We observed reduction in jitter (defined as a significant difference in jitter means before and after edrophonium, unpaired t-test P < 0.05) in 7 patients, no change in 8, and a significant increase in 2 patients. Blinded to their edrophonium results, the 17 patients were treated with pyridostigmine 180 mg/day for 1 month, with a subjective improvement of fatigue in 9 patients, and with a significant reduction in mean Hare fatigue scores in the entire group of 17 patients (pre=2.71, and post=1.71; Wilcoxan signed rank sum test, P < 0.05). Edrophonium-induced reduction of jitter on S-SFEMG was significantly associated with pyridostigmine-induced subjective improvement of fatigue (Fisher's exact test, P < 0.04). A significant reduction in fatigue with pyridostigmine was observed only in the 7 patients who experienced a significant reduction in jitter with edrophonium (Wilcoxan signed rank sum test, P=0.03). In addition, the 9 pyridostigmine responders experienced a significant reduction in jitter means pre- and post-edrophonium (100% vs. 88%, Bonferroni corrected, P < 0.01). We conclude that neuromuscular transmission as measured by jitter on S-SFEMG can improve with edrophonium in a proportion of PPS patients, and that generalized fatigue and muscle fatiguability in some patients with PPS may be due to anticholinesterase-responsive NMJ transmission defects.

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Title: Anticholinesterases in Post-Poliomyelitis Syndrome
[ Full Text Here ] Author(s): Daria A. Trojan and Neil R. Cashman
Original Publication: The Post-Polio Syndrome: Advances in the Pathogenesis and Treatment Volume 753 of the Annals of the New York Academy of Sciences May 25, 1995
Abstract/Extract: Our studies indicate that a proportion of fatigued post-poliomyelitis patients can experience an amelioration of defects in neuromuscular junction transmission and of clinical fatigue with anticholinesterases. Because S-SFEMG response was significantly associated with clinical response to anticholinesterases, fatigue in PPS may be caused by defects in neuromuscular junction transmission in a proportion of patients. Preliminary studies in a small group of patients indicate that anticholinesterases may produce their clinical neuromuscular response by producing an increase in isokinetic strength in a proportion of patients. Our studies provide a physiological rationale for the use of anticholinesterases in PPS for the symptom of fatigue. However, further randomized, placebo-controlled, double-blinded trials are needed to establish definitively the benefits and risks of these agents.

See also:
LincsPPN NewsBites Archive PRELIMINARY RESULTS OF TRIAL PRESENTED AT AAPM&R

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Title: Correlation of Electrophysiology with Pathology, Pathogenesis, and Anticholinesterase Therapy in Post-Polio Syndrome
[ Full Text Here ] Author(s): Neil R. Cashman and Daria A. Trojan
Original Publication: Reprinted from The Post-Polio Syndrome: Advances in the Pathogenesis and Treatment Volume 753 [pp 138-150] of the Annals of the New York Academy of Sciences May 25, 1995
Abstract/Extract: A great deal of data has been generated on PPS, and a great deal more will be generated before we understand the pathophysiology of this common and disabling disorder. Perhaps now, to guide future work and direct therapeutic approaches, it is best to think of the symptoms of PPS as due to two lesions of the motor unit: a "progressive lesion" and a "fluctuating lesion."

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Title: Stimulation frequency-dependent neuromuscular junction transmission defects in patients with prior poliomyelitis
[ Full Text Here ] Author(s): Daria A. Trojan, Daniel Gendron and Neil R. Cashman
Original Publication: Journal of the Neurological Sciences, 118 (1993) 150-157
Abstract/Extract: Generalized fatigue and muscle fatiguability are major symptoms of post-poliomyelitis syndrome (PPS), and may be due to neuromuscular junction transmission defects, as suggested by increased jitter on single fiber electromyography (SFEMG). To determine the etiology of this defect, we studied jitter at low (1, 5 Hz) and high (10, 15, 20 Hz) frequency stimulation with stimulation SFEMG in 17 post-polio patients with muscle fatiguability, and in 9 normal controls. In 5 of 17 PPS patients and in 1 of 9 controls, jitter was significantly higher (unpaired t-test, P < 0.05) at high frequency stimulation (HFS). In the remaining PPS patients and controls there was no significant difference in jitter at high and low stimulation frequencies. PPS patients with increased jitter at HFS had a significantly longer time interval since acute polio (mean 48.5 years) than PPS patients without increased jitter at HFS (mean 40 years; P < 0.05), but were not distinguished by other historical or clinical criteria. We conclude that the neuromuscular junction defect in post-polio patients is similar to that observed in amyotrophic lateral sclerosis, and is probably due to ineffective conduction along immature nerve sprouts and exhaustion of acetylcholine stores. The appearance of an increase in jitter with HFS in post-polio patients may be dependent upon time after acute polio.

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Title: An Open Trial of Pyridostigmine in Post-poliomyelitis Syndrome
[ Full Text Here ] Author(s): Daria A. Trojan and Neil R. Cashman
Original Publication: The Canadian Journal of Neurological Sciences Volume 22, No. 3 August 1995 223-227
Abstract/Extract:

Background: One of the major symptoms of postpoliomyelitis syndrome (PPS) is disabling generalized fatigue. Subjects with PPS also report muscle fatiguability and display electrophysiologic evidence of anticholinesterase-responsive neuromuscular junction transmission defects, suggesting that anticholinesterase therapy may be useful in the management of disabling fatigue. Methods: We initiated an open trial of the oral anticholinesterase pyridostigmine, up to 180 mg per day, in 27 PPS patients with generalized fatigue and muscle fatiguability. Response to Pyridostigmine was assessed with the Hare fatigue scale, the modified Barthel index for activities of daily living, and a modified Klingman mobility index. Results: Two patients could not tolerate the medication. After one month of therapy, 16 patients (64%) reported a reduction in fatigue on the Hare fatigue scale; three of 16 showed improvement on the modified Barthel index for activities of daily living, and two of 16 experienced improvement on a modified Klingman mobility index. Pyridostigmine responders were significantly more fatigued than non-responders on the pre-treatment Hare score, but were not significantly different with regard to age, sex, age at acute poliomyelitis, or severity of acute poliomyelitis. Conclusions: Pyridostigmine may be useful in the management of fatigue in selected patients with PPS. Response to pyridostigmine may be predicted by severity of pre-treatment fatigue.

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Title: Bromocriptine In The Treatment Of Post-Polio Fatigue:
A pilot study with implications for the pathophysiology of fatigue
[ Full Text Here ] Author(s): Richard L. Bruno, Ph.D., Jerald R. Zimmerman, M.D., Susan Creange, M.A., Todd Lewis, Ph.D., Terry Molzen, M.A., and Nancy M. Frick, M.Div, Lh.D.
Original Publication: American Journal of Physical Medicine and Rehabilitation, 1997 (in press)
Abstract/Extract:
Objective: Determine the effectiveness of bromocriptine in the treatment of severe and disabling post-polio fatigue.

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Title: Fainting And Fatigue: Causation or Coincidence
[ Full Text Here ] Author(s): Richard L. Bruno, Ph.D.
Original Publication: CFIDS Chronicle, 1996; 9(2): 37-39.
Abstract/Extract: As the former autonomic nervous system fellow at New York's Columbia-Presbyterian Medical Center, and in my current incarnation studying chronic fatigue in polio survivors, I have read with special interest the reports from Johns Hopkins University describing neurally mediated hypotension (NMH) in adults and adolescents with CFIDS.

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Polio and PPS Psychology

Title: Effect of Treatment and Noncompliance on Post-Polio Sequelae
[ Full Text Here ] Author(s): Paul E. Peach, MD, Stephen Olejnik, PhD
Original Publication: Orthopedics November 1991 Vol 14 No. 11 1199-1203.
Abstract/Extract: In this study of 77 patients with post-polio sequelae (PPS), symptoms and manual test scores on initial evaluation were compared with those at subsequent follow-up evaluations. Patients were divided into three groups based on the degree to which they had complied with clinically recommended interventions: compliers, partial compliers, and noncompliers. At the end of the followup period (2.2 ± 1.2 years), the mean muscle function scores of the entire study group had declined - l.5%, which represented a decline of -0.7% annually. On follow-up evaluations, the complier group had realized an improvement or resolution of post-polio symptoms, and also an improvement in muscle function of +0.6% annually. The partial complier group had realized either no improvement, or improvement in post-polio symptoms, but showed a further decline in muscle function of -3.0%, or an annual decline of -1.3%. The noncomplier group showed either no change, or a worsening of post-polio symptoms, and also showed a further decline in muscle function of - 4.1% which represented an annual decline of - 2.0%.

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Title: Polioencephalitis, Stress And The Etiology Of Post-Polio Sequelae
[ Full Text Here ] Author(s): Richard L. Bruno, Ph.D., Nancy M. Frick, M.Div., and Jesse Cohen, M.D.
Abstract/Extract: Post-mortum neurohistopathology from 158 individuals who contracted polio before 1950 are reviewed that document polio virus-induced lesions in reticular formation, hypothalamic, thalamic, peptidergic and monoaminergic neurons in the brain. This polioencephalitis was found to occur in every case of poliomyelitis, even those without evidence of damage to spinal motor neurons. These findings, in combination with data from the 1990 National Post-Polio Survey and new magnetic resonance imaging studies documenting post-encephalitis-like lesions in the brains of polio survivors, are used to present hypotheses that polioencephalitic damage 1) to aging reticular activating system and monoaminergic neurons is responsible for post-polio fatigue and 2) to enkephalin-producing neurons is responsible for hypersensitivity to pain in polio survivors. Hypotheses are also presented that the anti-metabolic action of glucocorticoids on polio-damaged, metabolically vulnerable neurons is responsible for the fatigue and muscle weakness reported by polio survivors during emotional stress. Suggestions for the treatment of Post-Polio Sequelae based on these hypotheses are also presented.

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Title: Postpoliomyelitis Syndrome: Assessment of Behavioral Features
[ Full Text Here ] Author(s): Donald L. Freidenberg, David Freeman, Steven J. Huber, Jacquelin Perry, Armin Fischer, Wilfred G. Van Gorp and Jeffrey L. Cummings
Original Publication: Neuropsychiatry, Neuropsychology, and Behavioral Neurology Vol. 2, No. 4, pp 272-281. 1989
Abstract/Extract: Postpoliomyelitis syndrome (PPS) is an increasingly recognized phenomenon characterized by late-onset weakness, pain, and fatigue. Psychiatric and cognitive disturbances have been noted in postpoliomyelitis patients, but the relationship of these symptoms to PPS is unknown. We examined postpoliomyelitis patients with and without PPS using objective neuropsychological and neuropsychiatric procedures. Our results suggest that disturbances of mood were common and that subtle cognitive deficits also occured in postpoliomyelitis patients. However, patients with PPS did not have greater depression or cognitive deficits compared to postpoliomyelitis patients without PPS.

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Title: Predicting Hyperactive Behavior as a Cause of Non-Compliance with Rehabilitation:
The Reinforcement Motivation Survey
[ Full Text Here ] Author(s): Dr. Richard L. Bruno
Abstract/Extract: Non-compliance with therapy is a significant problem in vocational rehabilitation. Significant amounts of professional time and money are wasted treating patients who are unwilling or unable to participate in their own rehabilitation. The client with chronic musculoskeletal pain - depressed, without energy (i.e., "anergic") and refusing to attend therapy - is the exemplar of non-compliance. However, clients with chronic pain and other disabilities demonstrate a different type of non-compliance, characterized by chronic hyperactivity and refusal to decrease behaviors that are known to maintain or increase symptoms. To document the occurrence of hyperactive non-compliance, 80 clients treated for chronic musculo skeletal pain (CMP) and 41 clients treated for Post-Polio Sequelae (PPS) were studied prospectively and administered the Beck Depression Inventory (BDI) and the Reinforcement Motivation Survey (RMS). Forty percent of the CMP clients and 79% of the PPS clients who were discharged from therapy demonstrated hyperactive non-compliance. CMP clients as a group had significantly elevated BDI and RMS Type A behavior and Negative Reinforcement Motivation scores, while PPS clients as a group had elevated Sensitivity to Criticism and Failure scores, as compared to controls. Significantly elevated Type A behavior and Sensitivity to Criticism and Failure scores were associated with hyperactive non-compliance as well as completion of therapy. These findings indicate that hyperactive non-compliance is an frequent cause of treatment failure in rehabilitation clients and that the RMS may be of use in identifying potentially non-compliant clients and the form non-compliance will take. The design of individualized rehabilitation programs to manage non-compliance and maximize the probability of completing therapy is described.

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Title: The Psychology Of Polio As Prelude To Post-Polio Sequelae:
Behavior modification and psychotherapy
[ Full Text Here ] Author(s): Richard L. Bruno, Ph.D. and Nancy M. Frick, M.Div.
Original Publication: Orthopedics, 1991, 14(11) :1185-1193.
Abstract/Extract: Even as the physical causes and treatments for Post-Polio Sequelae (PPS) are being identified, psychological symptoms - chronic stress, anxiety, depression and compulsive, Type A behavior - are becoming evident in polio survivors. Importantly, these symptoms are not only themselves causing marked distress but also are preventing patients from making the lifestyle changes necessary to treat their PPS. Neither clinicians nor polio survivors have paid sufficient attention to the acute polio experience, its conditioning of life-long patterns of behavior, its relationship to the development of PPS and its effect on the ability of individuals to cope with and treat their new symptoms. This paper describes the acute polio and post-polio experiences on the basis of patient histories, relates the experience of polio to the development of compulsive, Type A behavior, links these behaviors to the physical and psychological symptoms reported in the National Post-Polio Surveys and presents a multimodal behavioral approach to the treatment of PPS by describing patients who have been treated by this Post-Polio Service.

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Title: Stress and "Type A" Behavior as Precipitants of Post-Polio Sequelae:
The Felician/Columbia Survey
[ Full Text Here ] Author(s): Richard L. Bruno, PhD, and Nancy M. Frick, MDiv, LhD
Original Publication: In LS Halstead and DO Wiechers (Eds.): Research and Clinical Aspects of the Late Effects of Poliomyelitis. White Plains: March of Dimes Research Foundation, 1987.
Abstract/Extract: A behavioral profile has begun to emerge from studies of persons who survived acute poliomyelitis and are now experiencing post-polio sequelae. Persons who had polio have been shown to be employed full time at four times the rate of the general disabled population. Persons who had polio have more years of formal education on average than the general population, and marry at approximately the same rate as those who are not disabled. These data, combined with our own experience with thousands of persons who had polio, indicated that "polio survivors" are competent, hard-driving and time-conscious overachievers who demand perfection in all aspects of their personal, professional, and social lives. It appeared that those who survived polio exhibit "Type A" behavior and would therefore experience chronic emotional stress.

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Polio and PPS Physiology

Title: Gait Analysis Techniques
[ Full Text Here ] Author(s): JoAnne K. Gronley and Jacquelin Perry.
Original Publication: The Journal of American Physical Therapy Assn. Vol. 63, No. 12, December 1984 1831-1838.
Abstract/Extract: In the gait laboratory at Rancho Los Amigos Hospital, the emphasis is on patient testing to identify functional problems and determine the effectiveness of treatment programs. Footswitch stride analysis, dynamic EMG, energy-cost measurements, force plate, and instrumented motion analysis are the techniques most often used. Stride data define the temporal and distance factors of gait. We use this information to classify the patient's ability to walk and measure response to treatment programs. Inappropriate muscle action in the patient disabled by an upper motor neuron lesion is identified with dynamic EMG. Intramuscular wire electrodes are used to differentiate the action of adjacent muscles. We use the information to localize the source of abnormal function so that selection of treatment procedures is more precise. Force and motion data aid in determining the functional requirement and the muscular response necessary to meet the demand. Determining the optimum mode of locomotion and developing criteria for program planning have become more realistic with the aid of energy-cost measurements. Microprocessors and personal computer systems have made compact and reliable single-concept instrumentation available for basic gait analysis in the standard clinical environment at a modest cost. The more elaborate composite systems, however, still require custom instrumentation and engineering support.

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Title: Gastrointestinal Involvement In The Post-Polio Syndrome (PPS)
[ Full Text Here ] Our thanks to Tom Walter (TominCal@aol.com) for providing this article.
Author(s): Assembled by Tom Walter from talks Dr. Sinn Anuras gave in the early '90's, plus feedback he gave to some local participants.
Abstract/Extract: Gastrointestinal involvement is common in the post-polio syndrome, and it appears to affect the entire gastrointestinal tract. Unfortunately, there are only a few studies in this fascinating area. More extensive studies are needed to understand the pathologic and pathophysiologic processes in this problem, so that patients can be treated properly. We report our survey of gastrointestinal symptoms that could affect up to 50 per cent of the post-polio syndrome patients in this review. We also propose the underlying pathophysiologic changes, outline the diagnosis and treatment for difficulties of various parts of the gastrointestinal tract.

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Title: Late functional deterioration following paralytic poliomyelitis
[ Full Text Here ] Author(s): D. Kidd, R.S. Howard, A.J. Williams, F.W. Heatley, C.P. Panayiotopoulos and G.T. Spencer
Original Publication: QJ Med 1997; 90: 189 - 196
Abstract/Extract: Many patients with previous poliomyelitis develop 'post-polio syndrome' (PPS) in which late functional deterioration follows a period of relative stability. The frequency with which PPS can be attributed to clearly defined causes remains uncertain. We reviewed 283 newly-referred patients with previous poliomyelitis seen consecutively over a 4-year period; 239 patients developed symptoms of functional deterioration at a mean of 35 (5-65) years after the paralytic illness. Functional deterioration was associated with orthopaedic disorders in 170 cases, neurological disorders in 35, respiratory disorders in 19 and other disorders in 15. Progressive post-polio muscular atrophy was not observed. Functional deterioration following paralytic poliomyelitis is common, and associated with orthopaedic, neurological, respiratory and general medical factors which are potentially treatable.

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Title: Endurance Training Effect on Individuals With Postpoliomyelitis
[ Full Text Here ] Author(s): Brian Ernstoff, MD, Hakon Wetterqvist, MD, PhD, Henry Kvist, MD, PhD, Gunnar Grimby, MD, PhD
Original Publication: Arch Phys Med Rehabil 1996;77:843-8.
Abstract/Extract:

Objective: To determine the effects of an endurance training program on the exercise capacity and muscle structure and function in individuals with postpolio syndrome.

Design: Preexercise and postexercise testing was performed with muscle strength evaluations using isokinetic testing as well as hand-held Myometer. Muscle fatigue was determined by use of isokinetic testing, and endurance was determined by exercise testing. Enzymatic evaluation was performed with muscle biopsies taken at the same site; preexercise and postexercise muscle cross-sectional area was measured by computed tomography. Disability and psychosocial evaluation was performed by a Functional Status Questionnaire.

Setting: A university.

Subjects: Seventeen postpolio subjects ranging in age from 39 to 49 years volunteered for a 6-month combined endurance and strength training program. They had a history of acute poliomyelitis at least 25 years earlier and were able to walk with or without aid.

Intervention: Twelve of the subjects (mean age 42 years) completed the program, attending an average of 29 sessions, which were offered for 60 minutes twice a week.

Main Outcome Measures: Strength, endurance, enzymatic activity, and cross-sectional area were measured 3 months before the beginning of training, just before training, and at the completion of the exercise program.

Results: Knee extension was reduced to an average of 60% of control values and did not change with training. Strength measured with a hand-held Myometer increased significantly for elbow flexion, wrist extension, and hip abduction. Exercise test on a bicycle-ergometer showed significant reduction (6 beats/min) in heart rate at 70W and increase (12 beats/min) in maximal heart rate with training. The training program could be performed without major complications and resulted in an increase in muscle strength in some muscle groups and in work performance with respect to heart rate at submaximal work load.

© 1996 by the American Congress of Rehabilitation Medicine and the American Academy of Physical Medicine and Rehabilitation

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Title: Electrophysiology and Electrodiagnosis of the Post-Polio Motor Unit
[ Full Text Here ] Author(s): Daria A. Trojan, MD, Daniel Gendron, MD, Neil R. Cashman, MD
Original Publication: Orthopedics December 1991 Vol 14 No 12 1353-1361
Abstract/Extract: Post-poliomyelitis syndrome refers to new symptoms that may occur years after recovery from poliomyelitis. The most common of these symptoms are new weakness, fatigue, and pain. This article describes electrodiagnostic studies -- conventional electromyography (EMG), single fiber electromyography (SFEMG), and macroelectromyography (macro-EMG) -- that have provided information on the post-polio motor unit and on the possible etiology of some post-polio syndrome symptoms. Muscular fatigue, and indirectly, general fatigue, may be due to neuromuscular junction transmission defects in some post-polio individuals, as suggested by reduction of the compound motor action potentials on repetitive stimulation, and increased jitter and blocking on SFEMG. Progressive weakness and atrophy in post-polio syndrome is probably due to a distal degeneration of post-polio motor units with resultant irreversible muscle fiber denervation. Electrodiagnostic evidence of ongoing denervation includes fibrillation and fasciculation potentials on conventional EMG, increased jitter and blocking on SFEMG, and smaller macro-EMG amplitudes in newly weakened postpolio muscles. However, even though electrodiagnostic studies have provided insight into the possible causes of some postpolio syndrome symptoms, no specific electrodiagnostic test for the syndrome is currently available.

[ Index ]

Title: Electrodiagnostic Findings in 108 Consecutive Patients Referred to a Post-Polio Clinic - The Value of Routine Electrodiagnostic Studies
[ Full Text Here ] Author(s): Anne C. Gawne, Bao T. Pham, and Lauro S. Halstead.
Original Publication: The Post-Polio Syndrome: Advances in the Pathogenesis and Treatment Volume 753 pp 383-385 of the Annals of the New York Academy of Sciences May 25, 1995.
Abstract/Extract: Many patients with a history of polio develop new symptoms including weakness, pain, fatigue, and changes in function, or post-polio syndrome (PPS). Before a diagnosis of PPS is made, other diagnoses must first be ruled out. Assessment must be done in a comprehensive and coordinated manner. Therefore, as part of our routine evaluation, we do an electromyogram/nerve conduction study (EMG/NCS) on every patient. During examinations on our clinic patients we began to notice (1) electrodiagnostic evidence of polio in limbs not previously felt to be involved; (2) a normal EMG, or evidence of another disease; and (3) EMG evidence consistent with additional neurological lesions, including compression neuropathies, peripheral neuropathies, and radiculopathies. A prospective study using a routine, standardized four-extremity electrodiagnostic protocol was done to quantify the frequency of these occurrences.

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Title: Findings in Post-Poliomyelitis Syndrome
[ Full Text Here ] Author(s): Jacquelin Perry, M.D., James D. Fontaine, M.D. and Sara Mulroy, PH.D., P.T., Downey, California
Original Publication: The Journal of Bone and Joint Surgery Vol. 77-A, No. 8, August 1995, 1148-1153
Abstract/Extract: The purpose of this study was to identify overuse of muscles and other alterations in the mechanics of gait in twenty-one patients who had muscular dysfunction as a late consequence of poliomyelitis. All of the patients had good or normal strength (grade 4 or 5) of the vastus lateralis and zero to fair strength (grade 0 to 3) of the calf, as determined by manual testing.

Dynamic electromyography was used, while the patients were walking, to quantify the intensity and duration of contraction of the inferior part of the gluteus maximus, the long head of the biceps femoris. the vastus lateralis, and the soleus muscles. Patterns of contact of the foot with the floor, temporal-spatial parameters, and motion of the knee and ankle were recorded.

The principal mechanisms of substitution for a weak calf muscle fell into three groups: overuse of the quadriceps (twelve patients) or a hip extensor (the inferior part of the gluteus maximus in eight patients and the long head of the biceps femoris in four), or both; equinus contracture (twelve patients); and avoidance of loading-response flexion of the knee (five patients). Most patients used more than one method of substitution.

These obervations support the theory that postpoliomyelitis syndrome results from long-term substitutions for muscular weakness that place increased demands on joints, ligaments, and muscles and that treatment -- based on the early identification of overuse of muscles and ligamentous strain -- should aim at modification of lifestyle and include use of a brace.

[ Index ]

Title: Muscle Function, Muscle Structure, and Electrophysiology in a Dynamic Perspective in Late Polio
[ Full Text Here ] Author(s): Gunnar Grimby, MD, PhD, Erik Stålberg, MD.
Original Publication: Reprinted from POST-POLIO SYNDROME, edited by Halstead & Grimby, © 1995 Hanley & Belfus, Inc., Philadelphia, PA. Chapter 2, pp 15-24.
Abstract/Extract: The muscular impairment in patients with a history of polio varies from none to severe. The relationship between the degree of initial involvement and the effect of various compensatory mechanisms determines the clinical picture, which changes dynamically. Early and late recovery after poliomyelitis depend on a number of factors. Clinical improvement that appears within a few weeks after the acute phase is probably due to recovery in the excitability of functional, but not degenerated, motor neurons. Degeneration of neurons, causing peripheral denervation, is compensated by collateral sprouting, i.e., by nerve twigs branching off from surviving motor units overlapping with the denervated ones. This is most likely the main factor explaining recovery within the first 6-12 months. Another late compensatory process is the increase in size of the muscle fibers. As a result of these processes, normal muscle strength and presumably normal muscle volume can be seen despite a calculated loss exceeding 50% of the number of motor neurons.

[ Index ]

Title: Muscle Recovery in Poliomyelitis
[ Full Text Here ] Author(s): W. J. W. Sharrard, London, England
Original Publication: The Journal of Bone and Joint Surgery, Vol 37 B, No. 1, February 1955:63-79.
Abstract/Extract:
  1. The results of a three-year study of recovery in 3,033 lower limb muscles and 1,905 upper limb muscles in 142 patients are presented.
  2. The rate of recovery of partly paralysed muscles is the same in all muscles and muscle groups in the lower or upper limb. Clinical differences in the ability of individual muscles to recover depend upon the proportions of their number that remain permanently paralysed.
  3. The rate of recovery is slowest in adults and most rapid in young children.
  4. The amount of further recovery to be expected in a muscle can be predicted from knowledge of its grade at any time after one month from the onset of the paralysis. Fourteen-fifteenths of the total amount of recovery takes place by the beginning of the twelfth month; with rare exceptions individual muscle recovery is complete after twenty-four months.
  5. Ninety per cent of muscles that are still completely paralysed after six months remain permanently paralysed.
  6. The prognosis of a completely paralysed muscle is related to the level of paralysis in muscles supplied by the same spinal segments.
  7. Deterioration in power in a muscle is uncommon and, when it occurs, is associated with the presence of the strong opposing force of antagonist muscles or of gravity.
  8. The application of these findings to the management of cases of paralytic acute anterior poliomyelitis is discussed.

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Title: National Rehabilitation Hospital Limb Classification for Exercise, Research, and Clinical Trials in Post-Polio Patients
[ Full Text Here ] Author(s): Lauro S. Halstead, Anne Carrington Gawne, and Bao T. Pham
Original Publication: The Post-Polio Syndrome: Advances in the Pathogenesis and Treatment Volume 753 pp 343-353 of the Annals of the New York Academy of Sciences May 25, 1995.
Abstract/Extract: A need exists for an objective classification of polio patients for clinical and research purposes that takes into account the focal, asymmetric, and frequent subclinical nature of polio lesions. In order to prescribe a safe, effective exercise program, we developed a five-level (Classes I-V) limb-specific classification system based on remote and recent history, physical examination, and a four-extremity electrodiagnostic study (EMG/NCS). Class I limbs have no history of remote or recent weakness, normal strength, and a normal EMG. Class II limbs have no history of remote or recent weakness (or if remote history of weakness, full recovery occurred), normal strength and EMG evidence of prior anterior horn cell disease (AHCD). Class III limbs have a history of remote weakness with variable recovery, no new weakness, decreased strength, and EMG evidence of prior AHCD. Class IV limbs have a history of remote weakness with variable recovery, new clinical weakness, decreased strength, and EMG evidence of AHCD. Class V limbs have a history of severe weakness with little-to-no recovery, severely decreased strength and atrophy, and few-to-no motor units on EMG. In a prospective study of 400 limbs in 100 consecutive post-polio patients attending our clinic, 94 (23%) limbs were Class I, 88 (22%) were Class II, 95 (24%) were Class III, 75 (19%) were Class IV, and 48 (12%) were Class V. Guidelines for the use of this classification in a clinical/research setting are presented along with sample case histories and class-specific exercise recommendations.

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Title: The Distribution of the Permanent Paralysis in the Lower Limb in Poliomyelitis A Clinical and Pathological Study
[ Full Text Here ] Author(s): W. J. W. Sharrard, London, England
Original Publication: The Journal of Bone and Joint Surgery, Vol 37 B, No. 4, November 1955:540-558.
Abstract/Extract:

Though a striking feature of the paralysis that may result from an attack of poliomyelitis is its diversity, the belief that some order exists in the apparently irregular distribution of the permanent paralysis has been expressed by several authors. Wickman (1913) stated that "although a great variety of combinations of paralyses are found, certain types appear more often than others; in the leg the peroneal group and certain muscles of the thigh -- in my experience the quadriceps femoris especially -- tend to be implicated." Lovett and Lucas (1908), Lovett (1915, 1917), Jahss (1917), Mitchell (1925) and Legg (1929, 1937) showed tables indicating the relative frequency of paralysis and paresis in the muscles of the lower limb. All show a high incidence of paralysis in tibialis anterior, tibialis posterior, the long extensors of the toes and the peronei. A lower incidence of paralysis but a greater combined total of paralyses and pareses is shown in the quadriceps and in the gluteal muscles. No satisfactory explanation has yet been offered to account for these findings

It is the object of this paper to review the distribution of paresis and paralysis in the muscles of the lower limb, to account for its disposition in terms of the destruction of motor nerve cells in the lumbo-sacral spinal cord, and to indicate the practical application of the findings in the management of poliomyelitis.

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Title: Pulmonary dysfunction and its management in post-polio patients
[ Full Text Here ] Author(s): John R. Bach and Margaret Tilton
Original Publication: NeuroRehabilitation 8 (1997) 139-153
Abstract/Extract: Respiratory dysfunction is extremely common and entails considerable risk of morbidity and mortality for individuals with past poliomyelitis. Although it is usually primarily due to respiratory muscle weakness, post-poliomyelitis individuals also have a high incidence of scoliosis, obesity, sleep disordered breathing, and bulbar muscle dysfunction. Although these factors can result in chronic alveolar hypoventilation (CAH) and frequent pulmonary complications and hospitalizations, CAH is usually not recognized until acute respiratory failure complicates an otherwise benign upper respiratory tract infection. The use of non-invasive inspiratory and expiratory muscle aids, however, can decrease the risk of acute respiratory failure, hospitalizations for respiratory complications, and need to resort to tracheal intubation. Timely introduction of non-invasive intermittent positive pressure ventilation (IPPV), manually assisted coughing, and mechanical insufflation-exsufflation (MI-E) and non-invasive blood gas monitoring which can most often be performed in the home setting, are the principle interventions for avoiding complications and maintaining optimal quality of life © 1997 Elsevier Science Ireland Ltd.

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Title: Pulmonary Dysfunction and Sleep Disordered Breathing as Post-Polio Sequelae: Evaluation and Management
[ Full Text Here ] Author(s): John R. Bach, MD and Augusta S. Alba, MD
Original Publication: Orthopedics December 1991 Vol 14 No 12 1329-1337.
Abstract/Extract: Post-polio sequelae can include sleep disordered breathing and chronic alveolar hypoventilation (CAH). Both conditions develop insidiously and can render the post-polio survivor susceptible to cardiopulmonary morbidity and mortality when not treated in a timely and appropriate manner. These conditions can be diagnosed by a combination of spirometry, noninvasive blood gas monitoring, and ambulatory polysomnography Sleep disordered breathing is most frequently managed by nasal continuous positive airway pressure, while tracheostomy ventilation is the most common treatment for ventilatory failure. We report the more effective and comfortable techniques recently made available for managing sleep disordered breathing and the use of noninvasive treatment options for CAH, respiratory failure, and impaired airway clearance mechanisms. One hundred forty-three cases are reviewed.

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Title: Airway Secretion Clearance by Mechanical Exsufflation for Post-Poliomyelitis Ventilator-Assisted Individuals
[ Full Text Here ] Author(s): John R. Bach, MD, William H. Smith, Jennifier Michaels, MD, Lou Saporito, BA, Augusta S. Alba, MD, Rajeev Dayal, BS, Jeffrey Pan, BS
Original Publication: Arch Phys Med Rehabil Vol 74:170-177, February 1993.
Abstract/Extract: Pulmonary complications from impaired airway secretion clearance mechanisms are major causes of morbidity and mortality for post-poliomyelitis individuals. The purpose of this study was to review the long-term use of manually assisted coughing and mechanical insufflation-exsufflation (MI-E) by post-poliomyelitis ventilator-assisted individuals (PVAIs) and to compare the peak cough expiratory flows (PCEF) created during unassisted and assisted coughing. Twenty-four PVAIs who have used noninvasive methods of ventilatory support for an average of 27 years, relied on methods of manually assisted coughing and/or MI-E without complications during intercurrent respiratory tract infections (RTIs). Nine of the 24 individuals were studied for PCEF. They had a mean forced vital capacity (FVC) of 0.54 ± 0.47L and a mean maximum insufflation capacity achieved by air stacking of ventilator insufflations and glossopharyngeal breathing of 1.7L. The PCEF were as follows: unassisted, 1.78 ± 1.16L/sec; following a maximum assisted insufflation, 3.75 ± 0.73L/sec; with manual assistance by abdominal compression following a maximum assisted insufflation, 4.64 ± 1.42L/sec; and with MI-E, 6.97 ± 0.89L/sec. We conclude that manually assisted coughing and MI-E are effective and safe methods of airway secretion clearance for PVAIs with impaired expiratory muscle function who would otherwise be managed by endotracheal suctioning. Severely decreased maximum insufflation capacity but not vital capacity indicate need for a tracheostomy.
© 1993 by the American Congress of Rehabilitation Medicine and the American Academy of Physical Medicine and Rehabilitation

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NOTES

It is the intention of the Lincolnshire Post-Polio Network to make all the information we collect available regardless of our views as to it's content. The inclusion of a document in this library should not therefore be in any way interpreted as an endorsement.

People who had polio and are experiencing new symptoms need to be assessed by medical professionals who are experienced in Post-Polio to determine what is wrong and to give correct advice. We can only make these documents available to you. YOU must then take what you believe to be relevant to the medical professional you are seeing. We are collecting and collating everything we can to enable medical professionals to make informed decisions. Other medical conditions must be looked for first, Post-Polio Syndrome is by diagnosis of exclusion.

Whether you are a Polio Survivor, a friend or relation of a Polio Survivor, or a Medical Professional, we would advise you use this catalogue only to assist in determining your reading priorities. Every article in this library is likely to contain information of interest to both Polio Survivors and Medical Professionals.

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