Post Polio Syndrome

Introduction
• It is Late effects of poliomyelitis

• The term post polio syndrome (PPS) was first used at

the first International Post-Polio Conference in 1984.

• It occurs 35 years after acute onset

• The post polio sequel is a combination of neurological,

musculoskeletal and psychological manifestation.
• Definition
PPS is the neurological syndrome that describes new
and late symptoms of fatigue, progressive muscle
atrophy, weakness and pain in the survivors of acute
paralytic poliomyelitis.

• Significant proportion of polio patient develop PPS after

initial illness.

• Incidence of new symptoms.

• Predisposing Factors :
– Who have severe residual weakness
– Bulbar onset polio
– Old age during acute polio

• Post-polio syndrome is rarely life-threatening,

but the symptoms can significantly interfere
with an individual's ability to function
independently.
 Etiology
• There is insufficient evidence regarding exact
etiology of PPS.

• There are various theories :

– Loss of anterior horn cells during initial polio
– Remaining healthy motor neurons can no longer
maintain new sprouts
– Denervation exceeds reinervation
– Reactivation of a persistent latent virus.
– Infection of the motor neuron by a different enterovirus
Rare causes :
– Dysfunction of NMJ
– Age related changes superimposed with already
limited motor neuron pool after polio
– Overuse and fatigue of already weaken muscle
– Metabolic failure leading to an inability to
regenerate new sprout
Pathophysiology

(a) Normal motor units showing

healthy motor neurons, their axons
and the muscle fibers they
innervate.

(b) Initial polio virus with varying

numbers of motor neuron death
and denervation of their muscle
fibers (dotted line).
(c) Recovery from polio. Axons
from surviving motor neurons
sprout new fibers to innervate the
denervated muscle fibers.

(d) Early post-polio syndrome.

New loss of nerve fibers and
muscle fibre denervation.

(e) Late post-polio syndrome with

further loss of nerve fibers and
muscle fiber denervation.
 Symptoms
Symptoms appear after the long period of
recovery and neurological and functional
stability after acute viral infection (Acute
polio)

Progression of symptoms is comparatively

slow
Common symptoms :
• Profound fatigue
• Muscle weakness in previously affected or
unaffected group (New weakness)
• Muscle/Joint Pain
• Muscle Atrophy
• Cold intolerance
 Fatigue
• Described as increasing loss of strength during
exercise, increasing weakness and heavy sensation in
muscle
• Prominent in the early hours of the afternoon
• Increases with minimal physical activity
• Decreases with rest
• Decrease in muscular endurance
• Fatigue can be :
– Generalized fatigue
– Muscular fatigue
– Mental fatigue
 Weakness
• Due to :
• Disuse
• Overuse
• Chronic weakness
• Weight gain
• Inappropriate use
• Permanent weakness – Due to loss of motor unit
• Transient weakness – Due to fatigue
• Joint problems
• New muscle weakness : seen in stronger extremities.
 Muscle pain
• Extremely prevalent in PPS
• Deep aching pain
• Mainly occurs in extremities
• Myofascial pain syndrome / Fibromyalgia
• Small number of patients have muscle tenderness
on palpation
• Increases with activity and decreases with rest
• Joint pain :- usually results primarily from long term
microtrauma from abnormal biomechanical forces.
 Cold intolerance
• The involved extremity is abnormally cold
• ANS dysfunction
• May relate to sympathetic intermediolateral
column damage during acute poliomyelitis
• Peripheral component may include muscular
atrophy leading to reduced heat production
• Other symptoms :
– Breathing problems
– Hypoventilation Common in bulbar
– Sleep apnea Polio
– Swallowing difficulties
– Muscle fasciculation
– Muscle cramps
• All symptoms together will lead to reduced
mobility and difficulty in ADLs like walking,
dressing, climbing stairs etc.
 Investigation
• Laboratory investigation
• Joint X ray
• MRI/ CT Scan
• EMG
• NCV
 Medical Diagnosis
• The criteria most commonly used for establishing medical
diagnosis of PPS were developed by Halstead and vare
presented as follows:
I. A confirmed history of paralytic polio in childhood or
adolescence,
2. Partial to complete muscle strength and functional recovery.
3. A period of al least 15 years of neurological and funclional
stability.
4. Onset of two or more new problems
5. No other medical conditions to explain these new health
problems.
Management
 Pain management
• Heating modality / Cryotherapy*
• Activity restriction and lifestyle modification –
– Use of non fatiguating functional activities
– Avoid stairs, low chairs, and weight control
• Energy conservation techniques :
– Activity pacing
– More frequent rest period/ change of activity
– Reducing mechanical stress
– Supporting weak muscles
– Stabilizing abnormal joint movement
– Improving biomechanics of body
• Joint conservation technique :
– Encourage use of ergonomic devices
– chair elevators
– Bathtub bench or shower stool
– Weight control
– Ergonomic modification :
• Seating and workstation correction
• Ergonomic computer screen
• Wrist rests and keyboard
• Rolling cart for carrying items
 Joint pain
• Inhibiting muscle spasm
• Hydrotherapy
• ROM exercise – gentle passive ROM
• Mobilization
• Relaxation
• Meditation
• Stretching
• Orthosis
• Motorised mobility device
• NSAIDs
• Avoid strengthening and anerobic exercise
• Home management
– Rest
– Mechanical postural correction
– NSAIDs
– Pain free ROM
– Orthotics
 Fatigue Management
• Activity restriction and life style modification
• Energy conservation technique
• Light weight orthosis and assistive device
• Nap during day
• Motorized devices
• Relaxation Techniques
• Breathing exercise
• Meditation
 Postural deviation correction
• Strengthening + Orthosis  To correct deformity
• Postural exercise combined with breathing and
stretching exercise
• Mental imagery
• Ergonomics : Properly fitted electrical chairs, anterior tilt
seats, gleuteal pads, lumbar rolls, back support
• Thoraco lumbar corset – for abdominal muscle paralysis
• Soft foam collar or supportive micro cellular collar – for
neck muscle paralysis
 Locomotion
• Change in method of locomotion that do not
cause pain, weakness and fatigue.
• Use of cane, forearm crutches, trunk support,
shoe correction or orthosis.
• Motorized carts for distance locomotion
• Light weight manual wheelchairs
• Electrical wheelchair
• Personal mobility vehicles
A B
 Dysphasia
• Dietary changes and restrictions
• Breathing technique
• Swallowing exercise
• Monitoring fatigue and timing eating when
not fatigued
 Cardio pulmonary conditioning
• Aquatic exercise training
• Endurance training
• Aerobic exercise such as cycling, swimming,
and walking
 PULMONARY DYSFUNCTION
• Preventive measures
• Non-invasive positive
pressure ventilator assistance
(NIPPV)
• Breathing exercises: glossopharyngeal breathing
• Manual assisted coughing technique
• Pulmonary drainage
• Stop smoking
• If trunk supports are advised, vital capacity should be
checked with and Without an abdominal binder to
determine the effect on breathing.
 Sleep disturbance
• Habitual sleeping patterns history
• Modification of sleeping posture (avoid joint in
closed packed position)
• Foam mattress/ air pressure mattress
• Use of cervical pillows
 Cold intolerance
• Heating pad or hot water
• Control heat loss by clothing, massage and
local heat
 Weight reduction
- Simple way to decrease muscle work load.
- Weight loss is slow without exercise.
- Permanent modification of diet habit rather
than achieved in a short term diet.
- Dietetic counseling
Guidelines for functional exercise
• Consult with health care professional prior to
start an exercise program.
• AVOID overuse of muscle group
• Exercise programs of low to high intensity can
result in positive results.
• Short periods of activity are encouraged.
• Adequate rest between bouts of activity.
• Alternate days may be necessary for full recovery
• Use energy conservation and joint protection
techniques in regular routines.
• Incorporate breathing, relaxation, mental imagery, and
meditation exercises into daily activities.
• Proper body alignment during exercise and functional
activities
• Incorporate postural exercise and correction to
address malalignment and unnecessary use of muscles
and joint
 PSYCHOSOCIAL CONCERNS

• Post polio support groups

• Interdisciplinary approach
• Counselling from psychologists and
psychiatrists
• Vocational counselling
• Behaviour modification