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IMPORTANT NOTES FOR FIRST-TIME READERS

INDEX - T
Tansey, Catherine M., MSc
Thorsteinsson, Gudni. MD
Tilton, Margaret
Trojan, Daria A. MD

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Tansey, Catherine M., MSc

For articles with Tansey, Catherine M., MSc as co-author or contributor see the following catalogue entries:

T - Trojan, Daria A., MD
Article: Predictive Factors for Post-Poliomyelitis Syndrome

[ Index ]

Thorsteinsson, Gudni. MD

Dr. Thorsteinsson is currently located at Mayo Clinic Jacksonville.

Title: Subspecialty Clinics: Physical Medicine and Rehabilitation
Management of Postpolio Syndrome
[ Full Text Here ] Author(s): Gudni Thorsteinsson, M.D.
Original Publication: Mayo Clin Proc 1997;72:627-638
Abstract/Extract: Recent research has shed light on the pathogenesis of the postpolio syndrome and has helped explain its symptoms and the rationale for management. The aim of this article is to familiarize physicians with this syndrome. The history, acute infection, definition, and diagnosis are discussed, as well as the various symptoms and their management. People with postpolio syndrome can educate health professionals about this condition and can help others inflicted with this syndrome. Thus far, no cure is available. A correct diagnosis is important, and the physician must realize that severe comorbidities tend to afflict people with this syndrome. Numerous management options are available to help these people enjoy a high quality of life.

[ Index ]

Tilton, Margaret

For articles with Tilton, Margaret as co-author or contributor see the following catalogue entries:

B - Bach, John R., MD
Article: Pulmonary dysfunction and its management in post-polio patients

[ Index ]

Trojan, Daria A. MD

Co-Director of the Montreal Neurological Institute and Hospital Post-Polio Clinic.

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

[ Index ]

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.

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Title: Fibromyalgia Is Common in a Postpoliomyelitis Clinic
[ Full Text Here ] Author(s): Daria A. Trojan, MD, MSc, Neil R. Cashman, MD
Original Publication: The Archives of Neurology June 1995 Volume 52 620-624
Abstract/Extract:

Objective: To determine prospectively the occurrence and clinical characteristics of fibromyalgia in patients serially presenting to a postpolio clinic. Fibromyalgia may mimic some of the symptoms of postpoliomyelitis syndrome, a disorder characterized by new weakness, fatigue, and pain decades after paralytic poliomyelitis.

Design: Case series.

Setting: A university-affiliated hospital clinic.

Patients: One hundred five patients were evaluated with a standardized history and physical examination during an 18-month period. Ten patients were excluded because of the absence of past paralytic poliomyelitis.

Interventions: Patients with fibromyalgia were treated with low-dose, nighttime amitriptyline hydrochloride or other conservative measures.

Main Outcome Measures: Patients with fibromyalgia had diffuse pain and 11 or more of 18 specific tender points on examination (American College of Rheumatology criteria, 1990). Patients with borderline fibromyalgia had muscle pain and five to 10 tender points on physical examination.

Results: Ten (10.5%) of 95 postpolio patients met the criteria for fibromyalgia, and another 10 patients had borderline fibromyalgia. All patients with fibromyalgia complained of new weakness, fatigue, and pain. Patients with fibromyalgia were more likely than patients without fibromylagia to be female (80% vs 40%, P<.04) and to complain of generalized fatigue (100% vs 71%, P=.057), but were not distinguishable in terms of age at presentation to clinic, age at polio, length of time since polio, physical activity, weakness at polio, motor strength scores on examination, and the presence of new weakness, muscle fatigue, or joint pain. Approximately 50% of patients in both the fibromyalgia and borderline fibromyalgia groups responded to low-dose, nighttime amitriptyline therapy.

Conclusions: (1) Fibromyalgia occurs frequently in a postpolio clinic. (2) Fibromyalgia can mimic some symptoms of postpoliomyelitis syndrome. (3) Fibromyalgia in postpolio patients can respond to specific treatment.

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Title: Management of post-polio syndrome
[ Full Text Here ] Author(s): Daria A. Trojan, Lois Finch
Original Publication: NeuroRehabilitation 8 (1997) 93-105
Abstract/Extract: Many patients with post-poliomyelitis syndrome can benefit from a management program. When a post-polio patient presents with new symptoms, it is first essential to identify and treat other medical and neurological conditions which could produce these symptoms. New weakness can be managed with exercise (stretching, strengthening, and aerobic), avoidance of muscular overuse, weight loss, orthoses, and assistive devices. Fatigue can be managed with energy conservation techniques, lifestyle changes, pacing, regular rest periods or naps during the day, amitriptyline to improve sleep, and possibly pyridostigmine (trial in progress). The management of pain is dependent upon its cause. The treatment of post-polio muscular pain can include activity reduction, pacing (rest periods during activity), moist heat, ice, and stretching, use of assistive devices, and life style modifications. Fibromylagia can be treated with amitriptyline, cyclobenzaprine, and aerobic exercise. Joint and soft tissue abnormalities can be managed with modification of extremity use, physiotherapy, orthoses, assistive devices, non-steroidal anti-inflammatory medications, and rarely steroid injections and surgery. Superimposed neurological disorders may produce pain, and should be identified and treated. The identification and treatment of pulmonary dysfunction in a post-polio patient is an important aspect of management, and is discussed elsewhere in this issue. Dysphagia can be managed with diet changes, use of special breathing and swallowing techniques, monitoring fatigue and taking larger meals earlier and smaller meals later, and avoiding eating when fatigued. The management of psychosocial difficulties usually requires an interdisciplinary approach, and may include a post-polio support group, social worker, psychologist, and psychiatrist. 1997 Elsevier Science Ireland Ltd.

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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: 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: 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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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.

[ Index ]

For articles with Trojan, Daria A. MD as co-author or contributor see the following catalogue entries:

C - Cashman, Neil R., MD
Article: Correlation of Electrophysiology with Pathology, Pathogenesis, and Anticholinesterase Therapy in Post-Polio Syndrome

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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.

"Source" in the context of this catalogue primarily means original author. In a few cases it will be an organisation or conference.

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Document preparation: Chris Salter, Original Think-tank, Cornwall, United Kingdom.
Last modification: 1st February 2010.
Last information content change: 29th April 2000

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