In article <[log in to unmask]>, dated Thu, 4 Feb 1999 at 11:58:28,
[log in to unmask] writes
>Dear Chris, and all on the list
>
>I am new to the mailbase, so forgive me if this comes out wrong!
>
It came out fine, Lyn! Before I attempt to answer those questions concerning polio
may I add a preface. If you have web access I recommend you check out our online
library. We have over ninety articles, many from peer reviewed medical journals,
covering various aspects of post-polio conditions.
http://www.zynet.co.uk/ott/polio/lincolnshire/library.html
If you don't have web access, email me privately and I can either send you the text
of selected articles by email or arrange to have copies posted to you.
>I'm a British physiotherapist working in Kathmandu, mainly helping
>small organisations that work with the physically disabled.
>
>Many disabled in Nepal are disabled as a result of polio, and so I
>was interesteed in Chris Salter's comments about dangerous exercises
>for polio, and that exercises should be "non-fatiguing". "New
>weakness and fatigue" are new terms for me, but you seem to be
>suggesting that strengthening exercises that tire the muscles should
>not be done - is this just for muscles directly affected, or all
>muscles?
Not a simple answer as "non-fatiguing" and "strengthening" are not necessarily
mutually exclusive. I am not medically trained just an informed patient attempting to
increase awareness and provide easy access authoritative information. I therefore
always try to answer questions by quoting from articles authored by peer recognised
medical experts in the particular field.
"Exercise in post-polio patients has been a controversial topic for many years,
primarily because of case reports of overwork weakness in these patients [3,4].
These clinical findings were supported by studies in denervated muscles of rats
[5-8]. However, more recently, several studies have found that exercise can
result in an increase in strength in post-polio patients many years after the
acute illness. Feldman and Feldman and Soskolne [9,10] were the first to report
in more recent years the beneficial effects of an exercise program many years
after polio. Since then several other studies have confirmed their finding of
the benefical effects of an isotonic strengthening exercise program [11,12] as
well as isokinetic and isometric strengthening exercise programs [12-14]. In
addition, fiber density, jitter, blocking, median macro-electromyography motor
unit potential amplitude, and creatinine kinase were not changed significantly
with the exercise program [12]. In addition to strengthening exercise, aerobic
exercise has also been found to be beneficial in post-polio patients. Jones et
al. [15] found that the average level of aerobic fitness in post-polio patients
was 5.6 METS, or similar to that seen in patients just after a myocardial
infarction. Aerobic exercise both in the upper and lower extremities on a
bicycle ergometer [15-17], and on a treadmill [18] has been shown to be helpful.
The bicycle ergometer training programs resulted in similar training effects to
those observed in normals with improved maximum oxygen consumption, duration of
exercise, watts attained during exercise, and maximum expired volume per unit
time. Treadmill training resulted in improved economy or energy cost of walking,
and thus walking duration, but no change in cardiorespiratory conditioning.
Thus, exercise has been shown to be beneficial in post-polio
patients, even in muscles where new weakness has been reported. The
exact exercise prescription is dependent on a number of factors.
Isometric exercise is most useful in muscles with less than 3
strength (MRC scale), or in muscles over a painful joint. An
isotonic exercise program is most useful in muscles with grade 3 or
better strength, and without a painful joint. Isokinetic exercise
could also be used when equipment is available. An aerobic exercise
program such as using a bicycle ergometer, walking, or swimming can
also be useful, but preferably should be an activity which the
patient enjoys to increase compliance. A warm-up and cool-down
period with stretching exercises should be included [2]. Some
patients can also benefit from more agressive stretching of
contractures (if no contraindications exist), such as knee flexion
contractures and ankle plantarflexion contractures to improve gait
and stability. Early in the exercise program, it is best for
patients to be monitored carefully, to ensure that the exercise
prescription is being followed correctly and that overuse of
muscles and joints is not occurring. Once the patient understands
the exercise program well, and can self-monitor, less frequent
follow-up such as every few months is reasonable [19].
Even though several different types of exercise have been shown to
be beneficial in the late post-polio patient, exercise should be
used judiciously, and should be avoided completely in some
patients. Muscle groups which are being overused may benefit from
rest or supportive devices such as braces. In addition, these
studies have not assessed the effect of exercise programs on
patient function and general well-being, and the long term effects
of exercise in these patients are still unclear.
Overuse of muscles must be avoided in postpolio patients. Muscular
overuse in patients with past paralytic polio was thought to be the
cause of increased weakness in several case reports [3]. This new
weakness may be permanent. Perry et al. [20] performed dynamic
electromyography during gait in 34 PPS patients, and found evidence
for overuse (compared to normals). The usefulness of creatinine
kinase levels in the monitoring of overuse in post-polio patients
is unclear, however Waring and McLaurin [21] found a significant
correlation between CK levels and distance walked during ambulatory
activities in the previous 24 h, indicating that CK could be a
marker of overuse. In addition, in one case report [22], CK was
found to be markedly elevated in a post-polio patient with symptoms
of weakness, fatigue, and pain. With a reduction in exercise, serum
CK levels decreased and symptoms resolved."
>From "Management of post-polio syndrome"
Daria A. Trojan, Lois Finch
NeuroRehabilitation 8 (1997) 93-105
http://www.zynet.co.uk/ott/polio/lincolnshire/library/trojan/management.html
The above gives a general overview. It is worth expanding a couple of specific
aspects just a little. From the article cited in reference [20] above:
"The overly generous functional interpretation of the manual muscle
test grades exercised by most clinicians has complicated the postpolio
patients' ability to generate medical acceptance of their complaints.
Being unaware of this limitation in manual muscle testing, the
patients' physicians have failed to find any significant weakness. As a
result the general medical reaction, being reported by the patients,
has been to attribute the weakness and fatigue either to inadequate
exercise or psychological difficulties at work or home.
The problem of overuse also is poorly understood. It commonly is
assumed that fatigue develops only after sustained, vigorous effort.
Subclinical elements of fatigue, however, begin accumulating soon after
the onset of activity. Endurance is determined by the ratio between
intensity and duration of the muscular effort. Time tolerance
exponentially declines as the effort exceeds 15% maximum
strength.[16,27] This is true for both sustained and intermittent
function. The latter, by allowing periods of uninterrupted circulation,
delays the onset of fatigue.[5]"
>From "The Postpolio Syndrome - An Overuse Phenomenon"
Jacquelin Perry, M.D., Gregory Barnes, B.S., R.P.T. and JoAnne K. Gronley, M.A.,
R.P.T.
Clinical Orthopaedics and Related Research Volume 233:145-162; August 1988
http://www.zynet.co.uk/ott/polio/lincolnshire/library/perry/thepostpoliosyndrome.html
One other complication is the appreciation of the extent of 'polio damage' in polio
survivors. As long ago as 1955, Professor W. J. W. Sharrard wrote
"The quantitative relationship between the loss of motor nerve cells and the
residual power in muscles is particularly important in cases regarded as
aparalytic in the acute stage of poliomyelitis. Although there may never have
been any clinical paralysis, a considerable proportion of motor cells may have
been damaged or destroyed. The nerve supply to some muscles, especially those
supplied by short cell columns, may have been diminished by up to 60 per cent.
Patients without paralysis are frequently allowed to walk within two or three
weeks of the onset of the major illness. It is known that overstretching or
over-fatigue can occur in muscles such as the hip abductors or tibialis anterior
and may result in deterioration in power (Lovett 1915, 1917, Sharrard 1955).
Paresis, previously undetectable, may be revealed later by the development of a
limp or a valgus foot. It is probably wise, therefore, not to allow the
resumption of full activity in an aparalytic case at too early a date, and to
continue to look for evidence of paresis over a period of not less than six
months."
>From "The Distribution of the Permanent Paralysis in the Lower Limb in Poliomyelitis"
A Clinical and Pathological Study
W. J. W. Sharrard, London, England
The Journal of Bone and Joint Surgery, Vol 37 B, No. 4, November 1955:540-558
http://www.zynet.co.uk/ott/polio/lincolnshire/library/sharrard/dppllp.html
Unfortunately in the intervening years diagnostic advice has tended to include a
history of paralytic polio as a prerequisite for associating new muscle weakness and
fatigue with previous poliomyelitis. This has presented a diagnostic stumbling block
for many post-polio patients experiencing new symptoms of muscle weakness and
fatigue. In conversations with a number of recognised specialists in the field we can
report a growing consensus that the possibility of sub-clinical neuronal damage and
even sub-clinical polio should be considered in any diagnosis of new muscle weakness
and fatigue. I should make clear at this point that there are no definitive tests for
post-polio syndrome (post-polio sequelae or the late effects of polio) which includes
the symptoms of new muscle weakness and fatigue and is a clinical diagnosis arrived
at by exclusion of other possible conditions. We have just published an article that
explains the implications of sub-clinical neuronal damage.
"Non-Paralytic Polio and PPS"
Marcia Falconer, Ph.D. cell biology and Eddie Bollenbach, M.A. biology
A Lincolnshire Post-Polio Library Publication - January 1999
http://www.zynet.co.uk/ott/polio/lincolnshire/library/falconer/nonparalytic.html
> When is "new weakness and fatigue" likely to appear, and
>why?
"By sheer weight of numbers, persons experiencing the late effects of polio
finally started attracting the attention of the medical community, and in the
early 1980s the term post-polio syndrome was coined. Today the syndrome is
defined as a neurological disorder that produces a cluster of symptoms in
individuals who had recovered from paralytic polio many years earlier. These
symptoms typically appear from 30 to 40 years after the acute illness. The
major problems are progressive muscle weakness, debilitating fatigue, loss of
function and pain, especially in muscles and joints. Less common are muscle
atrophy, breathing problems, swallowing difficulties and cold intolerance. Of
all these health problems, however, the critical symptom of post-polio syndrome
is new progressive weakness."
and
"The extent of paralysis is unpredictable. Motor neurons that survive develop
new terminal axon sprouts in response to an unknown stimulus. These new sprouts
reinnervate, or reconnect, with the muscle fibers left orphaned by the death of
their original motor neurons. In a sense, the growth of additional axon sprouts
is the body's effort to keep as many orphaned muscle cells as possible alive and
working. A single motor neuron that initially stimulated 1,000 muscle cells
might eventually innervate 5,000 to 10,000 cells, creating a giant motor unit.
These vastly enlarged motor units make it possible for fewer motor neurons to do
the work of many.
Another adaptation that leads to increased strength is the enlargement of muscle
cells when they are regularly exercised. These two compensatory adaptations--
increase in muscle size and axon sprouting--are so effective that up to 50
percent of the original number of motor neurons can be lost without the muscle
losing clinically normal strength. These adaptations are neither static nor
permanent, however. To the contrary, after recovery from acute polio there is an
ongoing process of remodeling of the motor units that consists of both
denervation (losing old sprouts) and reinnervation (gaining new ones). It is
this process of remodeling or constant repair that allows the motor units to
achieve a steady state of muscle strength. When this steady state is disrupted,
new muscle weakness occurs."
>From "Post-Polio Syndrome"
Lauro S. Halstead
Scientific American April 1998 Vol 278 Number 4:36-41
http://www.zynet.co.uk/ott/polio/lincolnshire/library/halstead/sciampps.html
Our organisation is primarily concerned with late-effects simply because it was
started and is run by patients experiencing new problems following many years post-
recovery stability. We are nevertheless aware that there is another aspect of
concern, that being the best treatment protocols in the months and years immediately
following recovery from the initial infection. I do not have a clear answer as to how
the proposed mechanisms underlying these very real new late symptoms can be backward
applied to treatment protocols during immediate post-recovery of today's
poliomyelitis cases. For example, it is difficult to quantify what proportion of the
treatment I received some 40 years ago and which contributed to my significant
recovery from total paralysis, also laid the foundation for the new weakness and
fatigue I am now experiencing.
> You also mention "muscle fatigue" and "central fatigue" - could
>you explain more, about central fatigue in particular?
"Generalised [central] fatigue usually occurs every day and tends to progress
during the day. It is typically brought on by an accumulation of activities
carried out previously on a daily basis without special effort or noticeable
aftereffects. For many, it peaks midafternoon or early evening, a phenomenon
that feels like "hitting a wall." When this fatigue occurs, it is helpful for
individuals to stop what they are doing, rest, and, if possible, take a short
nap. Sometimes this is all it takes to reverse the fatigue and restore a
sufficient sense of energy and well-being to continue through the remainder of
the day without undue discomfort. Of all the new post-polio problems,
generalized fatigue is often the most distressing and disabling; it is difficult
to treat and imposes limits on people's lives without obvious physical changes
that others can easily identify.
Before making a diagnosis of PPS fatigue, it is necessary to exclude other
conditions that can cause this symptom. Some of the more common disorders
include anemia, depression, fibromyalgia (a musculoskeletal disorder that causes
generalized fatigue and pain), diabetes, thyroid disease, cancer, and autoimmune
disorders (where the body attacks itself).
Fatigue occuring upon wakening usually reflects sleep disturbances that can be
caused by a variety of conditions, including musculoskeletal pain, restless leg
syndrome, or respiratory abnormalities. Fatigue that lasts all day is not
typical of PPS and may indicate chronic fatigue syndrome among other diagnosis.
Depression can be associated with fatigue as can deconditioning, stress, and
obesity. Prescription medications, such as beta blockers or sedatives and over-
the-counter medications such as antihistamines, can contribute to feelings of
fatigue as well."
>From "Managing Post-Polio - A Guide to Living Well with Post-Polio Syndrome"
Edited by Lauro S. Halstead, M.D. Published by NRH Press 1998
More details can be found at
http://www.zynet.co.uk/ott/polio/lincolnshire/library/booklist/managing.html
The etiology underlying central fatigue in polio survivors is uncertain and is a
subject of debate amongst medical professionals specialising in post-polio
conditions.
>I'd really like to know how much I should be aware of these things,
>and whether Nepali rehabilitation workers (too few physios here!)
>should be encouraged to change their treatment accordingly.
Each polio patient should be assessed individually and a holistic approach used for
treatment protocols. Certainly, exercise that is painful and/or fatiguing is to be
avoided. The other side of the coin is total lack of exercise can also have
debilitating effects. It's a delicate balance.
>NB. The main textbook we use here is "Disabled Village Children" by
>David Werner, which I don't think mentions the above, certainly not
>in those terms - being in Kathmandu, there is limited access to
>reference books!
>
I thing I recognise the title in as much I believe I have seen it referenced on a web
site somewhere although I will have to check through my archives to locate it.
As far as further information is concerned, see my offer at the beginning of this
reply.
>While I'm on, is anyone out there involved in CBR work in developing
>countries? I'd be interested to be in touch with others who are
>involved at a non-hi-tech, grass-roots level!
>
As I don't understand that question I think it's time for me to stop writing! :-)
Hopefully, other physio subscribers will be able to answer that one.
My apologies for the length of this reply. On medical professional mailing lists I
limit myself to answering questions when they arise. When such opportunities for
increasing awareness arise, I hope I may be forgiven for going into some detail.
Best Regards,
Chris
--
Chris Salter (Vice Chairman) Lincolnshire Post-Polio Network
Registered Charity No. 1064177
<URL:http://www.zynet.co.uk/ott/polio/lincolnshire/>
Web Site & Vice Chairman Email: [log in to unmask]
Honorary Secretary Email: [log in to unmask]
Member of the British Healthcare Internet Association
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