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Post-Poliomyelitis Syndrome (PPS) the course of years.

This leads to distal


degeneration of the motor units and
Definition
worsening denervation, causing clinical
- It is a disorder typically characterized by the symptoms.
gradual onset and slow progression of new - Peripheral disintegration model Commented [JPE1]: Most widely held theory for PPS
weakness, fatigue, and pain in survivors of - Over-sprouting of new axon terminals from surviving
Physical Findings & Clinical Presentation LMNs occur in the immediate
paralytic poliomyelitis after a period of aftermath of the acute paralytic poliomyelitis
partial or complete recovery and many  New weakness and atrophy, asymmetrical, - This compensatory distal reinnervation expands the
years of neurologic stability. proximal and slowly progressive in size of motor units and provides effective motor function;
- The symptoms are persistent and cannot be distribution. Occurs in both initially weak and this stabilizes muscle strength for many years.
- However, this extensive nerve sprouting also increases
explained by the presence of other uninvolved muscles.
the metabolic burden of surviving LMNs, so after many
neurologic, medical, or orthopedic  Abnormal fatigue: may not be related to years, an un-identified process 1st causes nerve terminal
conditions activity levels, doesn't recover easily with dysfunction presenting as fatigue and then nerve
usual rest periods. terminal disintegration presenting as muscle weakness
Other Names and atrophy.
 Pain: myalgia, cramping pain, joint pain with
 Post-polio syndrome repetitive injury, hypersensitivities
 Decreased function with reduced Commented [JPE2]: Hitting a wall phenomenon/Polio
 Progressive post-poliomyelitis muscular wall: lack of energy with minimal activity; occurs primarily in
atrophy endurance for routine activities.
the afternoon
 Slow progression, either steady or step-wise Most disabling accompaniment and most debilitating
EPIDEMIOLOGY  Environmental cold intolerance symptoms; may affect patient’s cognition & thinking
 Brain fatigue-generator model Fatigue occurs commonly in late afternoon/early evening
Gender Atypical Fatigue: Fatigue that last throughout the day
 Sleep disturbances & weakness in respiratory
- Female > Male (Harrison’s Internal Medicine) system
-  Depression Commented [JPE3]: Joint pain may d/t wear & tear on
 Neurologic examination reveals evidence of joints, poor posture & deterioration of soft-tissue or
Incidence surgeries done to treat the residual effects of polio
asymmetric, lower motor neuron weakness
with or without musculoskeletal deformities Commented [JPE4]: More than 65% of individuals with
- Estimates vary from 22% to 85% of individuals
PPS have reported
who survive acute poliomyelitis secondary to longstanding polio such as
neck, shoulder, and back pain radiating to the hip and leg
asymmetric limb size, kyphoscoliosis, (Umphred)
Peak Incidence degenerative joint disease, and joint
Commented [JPE5]: Difficulty in concentration, memory
instability d/t the use of assistive devices and
- About 30 to 36 years following acute attention; damage in reticular formation, hypothalamus,
wheelchairs for decades dopaminergic neurons
poliomyelitis, although cases have been
 Postural abnormalities
reported between 8 and 71 years. Commented [JPE6]: Nocturnal hypoventilation occurs
Less Common Presentation less frequently
Risk Factors
Commented [JPE7]: -Forward head, forward-leaning
 Fasciculations
- Increasing age and greater length of time trunk, (-) lumbar curve, uneven pelvis, scoliosis, lateral trunk
 Dysphagia shifts
since the episode of acute poliomyelitis
 Dysarthria
- Acute poliomyelitis at an older age
- Greater severity of the acute poliomyelitis or Criteria for Diagnosing Post-Poliomyelitis Syndrome
chronic deficits after recovery
- AKA: Halstead-Ross Criteria
Pathology - Hx of polio
- recovery period & neurological stability at
- Loss of the anterior horn cell
least 15 years
Etiology - Onset of >2 S/Sx:
 fatigue,
- unknown; possible hyperfunctioning of  mm/joint pain
motor neurons, long-term overuse at high  weakness & atrophy in new mm,
levels resulting in new denervation  functional loss
(Siegelman)  cold intolerance
- The most popular hypothesis is - persistent S/Sx for 1 yr.
that the reduced population of enlarged - Rule out other diagnosis
motor units after acute poliomyelitis is
subject to increased stress and overuse over
- any sensory deficit is due to other etiology
(sensation is unaffected in PPS).
Ancillary Procedure
6. Respiratory Function
1. Nerve Conduction Velocity (NCV) - Examine for dyspnea, difficulty in speaking
- SNAP: Normal and weak cough
- CMAP: Abnormal (Low maximum CMAP 7. Aerobic Capacity
amplitudes) - use ergometer that involves both upper and
2. EMG lower extremities; e.g., Schwinn Air-Dyne,
- Abnormal activity discontinuous protocoL submaximal test
- Delayed Recruitment (ACSM recommendation)
- (+)Giant motor neuron unit, may indicative
Drugs
of chronic denervation and reinnervation
- Fasciculations can be unusually coarse and - There are no specific drugs to treat Post-
large in keeping with the giant motor units polio syndrome
detectable a. Anti-depressants
3. Low Rate Repetitive Stimulation (LRRS) - e.g., amitriptyline (Elavil), fluoxetine (Prozac)
- Normal activity b. Neurotransmitters inhibitors
4. SFEMG (Single Fiber EMG) - decreases fatigue and sleep disorders; e.g.,
- Increased jitter, fiber density and blocking serotonin, norepinephrine
5. Muscle Biopsy
- usually shows acute and chronic
neurogenic atrophy and often marked PT GOALS, OUTCOMES
group muscle fiber atrophy and fiber type
grouping 1. Maintain respiratory function
- Teach breathing exercises, supportive
Lab Exam cough maneuvers, postural drainage as
indicated
1. CBC, Electrolytes, Thyroid Function Test
2. Teach energy conservation techniques,
- To rule out other cause of fatigue
activity pacing: balance activity with
- Typically normal
frequent rest periods to decrease fatigue,
2. Erythrocyte Sedimentation Rate (ESR)
prevent overwork damage in weakened,
- Normal
denervated muscle.
- To rule out auto-immune disorders
- Teach relaxation techniques to maximize
- Increase Creatine-Kinase
rest
Examination - Avoid unnecessary activities to maximize
important work.
1. History
3. Preserve or increase muscle strength
- confirm original acute polio illness;
- Provide moderate exercise program (non-
document onset of present symptoms,
exhaustive exercise): modified strengthening
presentation, course, chronology.
and conditioning; use low-intensity,
2. Motor: strength, atrophy, muscle
discontinuous non-fatiguing exercise with
fatigue, muscle twitching and cramps
increased rest periods.
- strength, atrophy, muscle fatigue, muscle
- Caution against widespread use of strength
twitching and cramps
training, it may trigger fatigue
- Identify functional contractions (fair grades
- Consider pool programs: minimizes overwork Commented [JPE8]: Aquatic exercise can be very
or above)
relieves pain; general body conditioning beneficial because water decreases the stress on the joints,
- Look for spotty involvement, asymmetrical
4. Aerobic Conditioning bones, and muscles.
paralysis
- moderate to low-level training depending
3. ROM & Deformity
upon class of disease, discontinuous
4. Pain
protocol. In severe atrophic polio, exercise is
- Muscle pain: check tenderness to touch
contraindicated
- Skeletal, soft tissue pain: chronic overuse or
5. Maintain or increase function
poor alignment
5. Sensory function
- provide recommendations for lifestyle
modification; minimize abnormal postures,
gait deviations.
6. Prescribe appropriate orthoses, mobility aids Commented [JPE9]: The most frequently prescribed
(motorized cart), assistive devices, orthoses include
environmental modifications shoe lifts, AFOs (rocker bottom) and KAFOs.
7. Eliminate or control pain: provide options for
pain controL foster self-control
8. Teach patient and family all care, activities
of daily living; lifestyle modifications
9. Provide psychological support and
reassurance